Post on 16-Mar-2023
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Expenditure Summary
Service Category Claims PMPMAggregate
PMPMVariance in
PMPMPMPMTrend
Professional $21,407,337 $231.80 $179.30 29.28% -0.76%
Hospital IP $8,143,876 $88.18 $89.52 -1.49% -12.35%
Hospital OP $10,669,594 $115.53 $105.17 9.85% -0.33%
Pharmacy $9,959,524 $107.84 $82.12 31.33% 5.68%
DME, Transportation, Other $1,387,149 $15.02 $11.54 30.21% 20.55%
Preventive/Accidental Dental $0 $0.00 $1.34 -100.00% 0.00%
Total $51,567,481 $558.38 $468.99 19.06% -1.10%
All Packages/All Sites YTD Qtrly
Claims include IBNR
Note: The Aggregate PMPM for Preventive Dental services reflects the cost for coverage of children only.
Current Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
100_Ex_Expenditure_SummaryReport Id: 43735
Page 1 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Expenditure Summary
Service Category Claims PMPMAggregate
PMPMVariance in
PMPM
Professional $21,284,758 $233.57 $172.17 35.66%
Hospital IP $9,167,229 $100.60 $91.03 10.51%
Hospital OP $10,562,345 $115.91 $103.74 11.72%
Pharmacy $9,298,655 $102.04 $79.08 29.03%
DME, Transportation, Other $1,135,349 $12.46 $10.98 13.46%
Preventive/Accidental Dental $0 $0.00 $1.39 -100.00%
Total $51,448,336 $564.57 $458.40 23.16%
All Packages/All Sites YTD Qtrly
Claims include IBNR
Note: The Aggregate PMPM for Preventive Dental services reflects the cost for coverage of children only.
Prior Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
100_Ex_Expenditure_SummaryReport Id: 43735
Page 2 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Per Member Per Month Comparisons
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
100_Ex_Expenditure_SumReport Id: 43735
Page 3 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Professional Utilization by Major Practice Category
Major Practice Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid PerUnit PMPM
Variancein PMPM
PMPMTrend
Orthopedic and Arthritic Conditions $3,505,489.04 10.163 $44.82 $37.96 10.204 $34.45 $29.29 29.58% 10.64%Psychiatry $2,010,713.81 3.184 $82.05 $21.77 2.860 $65.49 $15.61 39.48% 12.86%Gastroenterology $1,385,614.16 3.939 $45.70 $15.00 3.903 $37.75 $12.28 22.20% 8.15%Endocrinology $1,357,506.90 6.394 $27.59 $14.70 3.758 $26.80 $8.39 75.17% -12.86%Preventive and Administrative Care $1,264,066.74 2.819 $58.27 $13.69 2.746 $58.21 $13.32 2.74% 6.87%Otolaryngology $1,243,410.90 3.205 $50.41 $13.46 2.881 $41.72 $10.02 34.42% 15.44%Cardiology $1,148,415.74 2.494 $59.84 $12.44 2.151 $52.71 $9.45 31.61% -6.18%Cancer $1,104,139.95 3.564 $40.26 $11.96 4.625 $37.91 $14.61 -18.17% -50.70%Dermatology $1,000,118.29 1.921 $67.64 $10.83 1.850 $51.58 $7.95 36.15% 7.76%Gynecology $959,502.55 4.950 $25.19 $10.39 3.505 $26.18 $7.65 35.89% 4.42%Ophthalmology $826,545.61 1.483 $72.43 $8.95 1.467 $57.30 $7.01 27.76% 1.13%Neurology $807,969.22 2.568 $40.88 $8.75 2.475 $34.79 $7.18 21.91% 9.79%Obstetrics $752,073.11 1.741 $56.14 $8.14 2.196 $45.46 $8.32 -2.09% -0.37%Pulmonology $498,314.61 0.759 $85.36 $5.40 0.920 $51.99 $3.99 35.33% 11.11%Other $468,907.30 2.200 $27.70 $5.08 2.337 $19.50 $3.80 33.70% 27.64%Urology $369,618.88 1.225 $39.20 $4.00 1.287 $31.10 $3.34 19.98% -1.48%Isolated Signs/Symptoms $314,852.94 0.986 $41.48 $3.41 0.876 $38.39 $2.80 21.62% -13.89%Chemical dependency $243,128.82 0.240 $131.42 $2.63 0.243 $59.70 $1.21 118.17% 96.27%Hepatology $185,943.22 0.732 $32.99 $2.01 0.685 $29.03 $1.66 21.43% -28.47%Hematology $185,596.04 2.688 $8.97 $2.01 1.041 $10.09 $0.87 129.72% 34.90%Infectious diseases $109,137.04 0.320 $44.26 $1.18 1.303 $17.90 $1.94 -39.20% 7.27%Nephrology $107,840.79 0.169 $82.89 $1.17 0.257 $39.26 $0.84 39.11% -16.43%Neonatology $81,055.13 0.077 $136.00 $0.88 0.155 $106.92 $1.39 -36.65% -32.31%Late effects/Complications $65,256.49 0.126 $67.48 $0.71 0.229 $30.26 $0.58 22.22% -1.39%Total $19,995,217 57.948 $44.84 $216.51 53.956 $38.58 $173.48 24.80% -0.83%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2018 12:00:00 AMRun Date: 02/12/2018
© Copyright 2018 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 4 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional Utilization by Major Practice Category
Major Practice Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid PerUnit PMPM
Variancein PMPM
Orthopedic and Arthritic Conditions $3,126,588.50 10.299 $39.98 $34.31 10.293 $33.12 $28.41 20.77%Cancer $2,211,148.57 5.616 $51.85 $24.26 5.372 $31.70 $14.19 70.95%Psychiatry $1,757,458.40 2.806 $82.49 $19.29 2.797 $62.19 $14.50 33.04%Endocrinology $1,537,632.01 6.128 $33.04 $16.87 4.684 $22.42 $8.75 92.83%Gastroenterology $1,264,019.48 4.224 $39.41 $13.87 3.745 $36.16 $11.29 22.91%Cardiology $1,208,606.34 2.365 $67.29 $13.26 2.183 $52.14 $9.48 39.83%Preventive and Administrative Care $1,167,368.65 2.618 $58.71 $12.81 2.824 $56.01 $13.18 -2.84%Otolaryngology $1,062,173.53 2.599 $53.82 $11.66 2.926 $38.80 $9.46 23.19%Dermatology $916,046.05 1.859 $64.90 $10.05 1.780 $52.57 $7.80 28.94%Gynecology $906,611.14 4.889 $24.42 $9.95 3.924 $22.75 $7.44 33.74%Ophthalmology $806,139.71 1.432 $74.11 $8.85 1.433 $56.04 $6.69 32.18%Obstetrics $744,383.00 1.834 $53.44 $8.17 1.957 $47.72 $7.78 4.97%Neurology $726,000.44 2.582 $37.02 $7.97 2.312 $36.11 $6.96 14.54%Pulmonology $443,089.51 0.853 $68.42 $4.86 1.067 $44.18 $3.93 23.83%Urology $369,697.58 1.485 $32.78 $4.06 1.383 $29.15 $3.36 20.77%Other $362,276.91 1.622 $29.41 $3.98 1.183 $21.60 $2.13 86.67%Isolated Signs/Symptoms $360,505.62 1.105 $42.97 $3.96 0.960 $38.43 $3.07 28.66%Hepatology $255,813.66 1.050 $32.09 $2.81 0.723 $27.82 $1.68 67.47%Hematology $136,113.46 2.447 $7.32 $1.49 0.772 $15.04 $0.97 54.43%Nephrology $127,388.18 0.386 $43.42 $1.40 0.387 $30.55 $0.99 41.78%Chemical dependency $121,677.65 0.252 $63.71 $1.34 0.288 $38.04 $0.91 46.39%Neonatology $118,585.24 0.092 $170.63 $1.30 0.145 $112.41 $1.36 -4.17%Infectious diseases $100,041.31 0.208 $63.28 $1.10 0.773 $28.10 $1.81 -39.39%Late effects/Complications $65,357.98 0.207 $41.50 $0.72 0.201 $29.22 $0.49 46.82%Total $19,894,723 58.957 $44.44 $218.32 54.112 $36.95 $166.62 31.03%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2018 12:00:00 AMRun Date: 02/12/2018
© Copyright 2018 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 5 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Professional PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Prior Aggregate
Report Period: 2/1/2018 12:00:00 ARun Date: 02/12/2018
© Copyright 2018 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 6 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Professional Utilization by Service Category
Service Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid perUnit PMPM
Variance inPMPM
PMPMTREND
Office Visit $4,306,561 3.406 $164.28 $46.63 3.069 $125.32 $32.05 45.49% -0.09%
Surgery $4,303,363 18.109 $30.88 $46.60 17.565 $26.35 $38.58 20.80% 8.95%
Radiology / Lab / Pathology $3,280,676 9.890 $43.10 $35.52 8.653 $39.68 $28.61 24.17% -11.02%
Injections / Immunizations / IV Therapy $2,226,484 16.493 $17.54 $24.11 14.573 $17.26 $20.97 14.99% -18.38%
Hospital / Institutional Visits $1,158,353 0.540 $278.58 $12.54 0.486 $239.57 $9.71 29.17% 6.36%
Mental Health $1,125,598 2.273 $64.35 $12.19 1.996 $55.22 $9.19 32.69% 16.65%
Other Visits / Procedures $1,124,115 1.861 $78.49 $12.17 1.963 $55.25 $9.04 34.68% 4.20%
Physical Exam $869,371 0.538 $209.89 $9.41 0.550 $205.78 $9.43 -0.15% 6.93%
Physical Therapy / Chiropractic $517,107 2.893 $23.23 $5.60 3.034 $21.90 $5.54 1.12% 5.66%
Maternity Care and Delivery $402,851 0.050 $1,049.09 $4.36 0.055 $975.62 $4.46 -2.13% 6.08%
Routine Eye Care $332,774 0.339 $127.60 $3.60 0.333 $106.40 $2.96 21.90% 2.56%
Allergy / Dermatology $187,620 0.939 $25.95 $2.03 0.669 $18.33 $1.02 98.77% 34.44%
Chemotherapy $55,064 0.035 $205.46 $0.60 0.053 $151.90 $0.67 -10.82% -41.75%
Consults $38,472 0.043 $115.88 $0.42 0.039 $143.06 $0.47 -10.74% -17.65%
Supplies $31,786 0.425 $9.71 $0.34 0.752 $5.29 $0.33 3.92% -12.82%
E-Visits $20,394 0.062 $42.85 $0.22 0.080 $47.10 $0.31 -29.64% 4.76%
Chemical Health $14,628 0.051 $37.22 $0.16 0.085 $23.03 $0.16 -3.16% 23.08%
Total $19,995,217 57.948 $44.84 $216.51 53.956 $38.58 $173.48 24.80% -0.83%
All Packages/All Sites YTD Qtrly
AggregateCurrent Year Actual
Note: Claims do not include IBNR
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
120_Ex_Professional_by_CategoryReport Id: 43735
Page 7 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional Utilization by Service Category
Service Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid perUnit PMPM
Variance inPMPM
Office Visit $4,252,744 3.458 $161.97 $46.67 3.086 $120.72 $31.05 50.32%
Surgery $3,897,323 18.709 $27.43 $42.77 17.781 $24.87 $36.84 16.08%
Radiology / Lab / Pathology $3,637,518 11.008 $43.52 $39.92 8.766 $38.20 $27.91 43.04%
Injections / Immunizations / IV Therapy $2,692,177 16.351 $21.68 $29.54 14.801 $16.14 $19.91 48.41%
Hospital / Institutional Visits $1,074,584 0.511 $277.10 $11.79 0.511 $222.61 $9.48 24.36%
Other Visits / Procedures $1,064,533 1.902 $73.71 $11.68 1.877 $55.70 $8.71 34.10%
Mental Health $952,127 1.847 $67.90 $10.45 1.725 $56.43 $8.11 28.79%
Physical Exam $801,627 0.509 $207.19 $8.80 0.531 $205.17 $9.08 -3.07%
Physical Therapy / Chiropractic $483,054 2.653 $23.97 $5.30 2.949 $21.51 $5.29 0.29%
Maternity Care and Delivery $374,089 0.067 $732.07 $4.11 0.054 $961.86 $4.36 -5.87%
Routine Eye Care $320,026 0.343 $122.90 $3.51 0.334 $103.75 $2.89 21.55%
Allergy / Dermatology $137,320 0.848 $21.31 $1.51 0.716 $17.22 $1.03 46.54%
Chemotherapy $93,673 0.046 $267.64 $1.03 0.048 $177.49 $0.71 45.29%
Consults $46,683 0.048 $127.55 $0.51 0.036 $144.85 $0.43 18.47%
Supplies $35,626 0.563 $8.33 $0.39 0.731 $5.49 $0.33 16.89%
E-Visits $19,416 0.064 $40.12 $0.21 0.078 $51.58 $0.33 -36.26%
Chemical Health $12,206 0.030 $53.77 $0.13 0.087 $22.62 $0.16 -18.72%
Total $19,894,723 58.957 $44.44 $218.32 54.112 $36.95 $166.62 31.03%
All Packages/All Sites YTD Qtrly
AggregatePrior Year Actual
Note: Claims do not include IBNR
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
120_Ex_Professional_by_CategoryReport Id: 43735
Page 8 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Professional PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
120_Ex_Professional_by_Report Id: 43735
Page 9 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Inpatient Utilization by Major Practice Category
Major Practice Category ClaimsAdmits
per 1000Paid per
AdmitDays
per 1000 PMPMAdmits per
1000Paid Per
AdmitDays
per 1000 PMPMVariancein PMPM
PMPMTrend
Cardiology $1,590,160 6.1 $33,833 28.2 $17.22 4.4 $30,307 20.2 $11.22 53.44% 4.87%Orthopedic and Arthritic Conditions $1,397,069 7.1 $25,401 27.2 $15.13 7.7 $23,233 33.0 $14.83 2.02% -22.25%Obstetrics $798,590 13.4 $7,753 31.1 $8.65 13.6 $7,697 34.0 $8.72 -0.84% -5.88%Gastroenterology $467,811 4.2 $14,619 14.2 $5.07 4.0 $15,514 14.9 $5.19 -2.35% -26.52%Cancer $413,951 2.2 $24,350 12.3 $4.48 3.3 $26,299 16.2 $7.25 -38.14% 1.82%Psychiatry $408,136 4.2 $12,754 28.8 $4.42 4.0 $14,725 44.3 $4.87 -9.33% 108.49%Infectious diseases $359,191 1.9 $23,946 10.7 $3.89 2.0 $23,021 11.0 $3.80 2.46% 30.98%Neurology $349,732 2.9 $15,897 28.6 $3.79 2.8 $23,626 23.5 $5.58 -32.16% -30.59%Chemical dependency $347,895 4.2 $10,872 57.6 $3.77 2.4 $11,319 36.3 $2.24 67.85% 114.20%Endocrinology $294,229 2.2 $17,308 5.6 $3.19 1.7 $18,945 6.5 $2.75 15.77% 39.30%Pulmonology $253,887 2.6 $12,694 19.0 $2.75 2.9 $19,303 15.7 $4.67 -41.07% -33.25%Neonatology $199,812 9.2 $2,814 20.0 $2.16 10.9 $7,882 35.0 $7.16 -69.78% -55.83%Gynecology $184,075 1.7 $14,160 3.6 $1.99 0.6 $14,353 1.4 $0.77 157.88% 32.67%Urology $107,300 1.0 $13,412 3.6 $1.16 0.9 $11,220 3.0 $0.84 37.82% -25.16%Dermatology $98,674 1.2 $10,964 5.1 $1.07 1.0 $9,876 5.0 $0.80 33.60% -44.27%Hepatology $94,954 1.6 $7,913 4.8 $1.03 1.5 $19,332 5.9 $2.35 -56.22% -83.62%Late effects/Complications $71,686 0.9 $10,241 1.9 $0.78 0.7 $18,202 2.5 $1.09 -28.56% 14.71%Otolaryngology $43,079 0.6 $8,616 1.6 $0.47 0.6 $13,043 1.4 $0.70 -33.06% 0.00%Hematology $32,628 0.5 $8,157 0.9 $0.35 0.4 $12,913 1.1 $0.42 -14.88% 0.00%Other $18,845 0.1 $18,845 0.8 $0.20 0.1 $27,066 0.3 $0.12 64.19% 1,900.00%Nephrology $12,947 0.1 $12,947 0.3 $0.14 0.6 $21,997 3.2 $1.05 -86.61% -83.33%Ophthalmology $10,097 0.1 $10,097 0.4 $0.11 0.1 $17,939 0.3 $0.11 -2.66% 0.00%Preventive and Administrative Care $1,272 0.0 $0 0.0 $0.01 0.1 $19,510 0.8 $0.13 -89.43% -50.00%Isolated Signs/Symptoms $0 0.0 $0 0.0 $0.00 0.0 $25,379 0.1 $0.04 -100.00% 0.00%Total $7,556,020 68.1 $14,420 306.1 $81.82 66.2 $15,704 315.4 $86.70 -5.63% -12.34%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2018 12:00:00 AMRun Date: 02/12/2018
© Copyright 2018 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 10 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Inpatient Utilization by Major Practice Category
Major Practice Category ClaimsAdmits
per 1000Paid per
AdmitDays
per 1000 PMPMAdmits per
1000Paid Per
AdmitDays
per 1000 PMPMVariancein PMPM
Orthopedic and Arthritic Conditions $1,773,186 9.7 $23,962 36.5 $19.46 7.9 $21,023 34.9 $13.87 40.33%Cardiology $1,496,020 4.5 $44,001 22.3 $16.42 4.8 $27,763 23.1 $11.05 48.57%Obstetrics $837,155 12.9 $8,542 38.5 $9.19 13.6 $7,472 34.3 $8.45 8.68%Gastroenterology $628,406 5.3 $15,710 19.6 $6.90 3.5 $14,629 13.4 $4.25 62.27%Hepatology $573,557 3.0 $24,937 13.7 $6.29 1.0 $18,183 3.8 $1.48 326.39%Neurology $497,313 3.3 $19,893 18.7 $5.46 3.5 $31,238 28.9 $9.18 -40.58%Neonatology $445,632 9.7 $6,022 27.8 $4.89 11.1 $5,397 30.4 $5.00 -2.28%Cancer $400,566 2.1 $25,035 6.6 $4.40 3.3 $27,983 17.3 $7.75 -43.27%Pulmonology $375,340 2.6 $18,767 16.2 $4.12 2.8 $19,061 12.9 $4.47 -7.96%Infectious diseases $270,533 1.2 $30,059 5.9 $2.97 1.3 $15,407 6.4 $1.70 74.25%Endocrinology $208,299 2.0 $13,887 4.6 $2.29 2.7 $26,078 13.4 $5.84 -60.83%Psychiatry $193,180 2.4 $10,732 13.7 $2.12 4.1 $13,332 37.3 $4.56 -53.54%Dermatology $174,614 0.5 $43,654 1.8 $1.92 0.6 $10,505 3.0 $0.49 292.14%Chemical dependency $160,748 2.5 $8,460 27.3 $1.76 2.3 $12,465 32.0 $2.34 -24.65%Urology $141,136 1.1 $17,642 2.6 $1.55 0.8 $14,058 2.6 $0.90 71.96%Gynecology $136,934 1.3 $13,693 2.8 $1.50 0.7 $14,383 1.7 $0.88 70.06%Nephrology $76,540 0.8 $12,757 2.9 $0.84 0.8 $32,235 5.7 $2.11 -60.15%Late effects/Complications $62,148 0.7 $12,430 2.8 $0.68 0.6 $16,129 2.0 $0.84 -19.03%Otolaryngology $42,794 0.4 $14,265 1.2 $0.47 0.7 $18,407 2.7 $1.01 -53.49%Ophthalmology $9,718 0.1 $9,718 0.1 $0.11 0.1 $11,449 0.2 $0.07 51.62%Preventive and Administrative Care $1,590 0.0 $0 0.0 $0.02 0.5 $25,214 2.8 $1.02 -98.29%Other $914 0.0 $0 0.0 $0.01 0.1 $34,732 0.9 $0.21 -95.30%Hematology $0 0.0 $0 0.0 $0.00 0.5 $16,356 1.9 $0.63 -100.00%Isolated Signs/Symptoms $0 0.0 $0 0.0 $0.00 0.0 $13,307 0.1 $0.04 -100.00%Total $8,506,323 66.1 $16,945 265.5 $93.34 67.2 $15,752 311.8 $88.15 5.89%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2018 12:00:00 AMRun Date: 02/12/2018
© Copyright 2018 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 11 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Top 10 Inpatient PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Current Aggregate
Report Period: 2/1/2018 12:00:00 ARun Date: 02/12/2018
© Copyright 2018 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 12 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Inpatient Utilization by Service Category
Service Category ClaimsAdmits
per 1000Paid Per
AdmitDays per
1000 PMPMAdmits per
1000Paid per
AdmitDays per
1000 PMPMVariancein PMPM
PMPMTrend
Surgical $3,522,949 15.1 $30,370 48.7 $38.15 15.0 $32,424 54.9 $40.41 -5.61% -27.37%
Medical $1,768,857 19.2 $11,952 59.6 $19.15 17.8 $12,885 60.7 $19.08 0.37% 8.99%
Maternity $798,596 13.4 $7,753 31.1 $8.65 13.6 $7,667 33.9 $8.67 -0.30% -5.88%
Mental Health $366,483 3.8 $12,637 24.8 $3.97 3.4 $13,131 23.8 $3.74 6.15% 198.50%
Chemical Health $346,883 4.0 $11,190 59.0 $3.76 2.7 $13,873 54.7 $3.12 20.56% 102.15%
Other Treatments $302,050 1.2 $33,561 4.3 $3.27 0.6 $42,847 2.3 $2.24 46.29% -29.53%
Non-Acute $262,861 2.3 $14,603 58.7 $2.85 2.3 $11,442 50.1 $2.22 28.15% 114.29%
Newborn $187,341 9.1 $2,676 19.9 $2.03 10.9 $7,960 35.0 $7.21 -71.88% -58.49%
Total $7,556,020 68.1 $14,420 306.1 $81.82 66.2 $15,704 315.4 $86.70 -5.63% -12.34%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Current Year Actual
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
140_Ex_Inpatient_By_CategoryReport Id: 43735
Page 13 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Inpatient Utilization by Service Category
Service Category ClaimsAdmits
per 1000Paid Per
AdmitDays per
1000 PMPMAdmits per
1000Paid per
AdmitDays per
1000 PMPMVariancein PMPM
Surgical $4,787,321 19.5 $32,347 74.1 $52.53 16.0 $31,569 61.0 $42.07 24.87%
Medical $1,600,847 16.3 $12,910 58.7 $17.57 17.5 $13,841 63.8 $20.20 -13.04%
Maternity $837,155 12.9 $8,542 38.5 $9.19 13.5 $7,434 34.5 $8.38 9.67%
Newborn $445,243 9.7 $6,017 27.8 $4.89 11.3 $6,787 34.0 $6.39 -23.52%
Other Treatments $423,252 0.9 $60,465 5.0 $4.64 0.6 $52,508 2.9 $2.65 75.29%
Chemical Health $169,640 2.5 $8,928 27.9 $1.86 2.4 $14,608 42.5 $2.93 -36.45%
Mental Health $121,582 2.0 $8,105 7.2 $1.33 3.1 $11,866 20.9 $3.04 -56.05%
Non-Acute $121,283 2.2 $7,134 26.2 $1.33 2.7 $10,907 52.1 $2.50 -46.73%
Total $8,506,323 66.1 $16,945 265.5 $93.34 67.2 $15,752 311.8 $88.15 5.89%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Prior Year Actual
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
140_Ex_Inpatient_By_CategoryReport Id: 43735
Page 14 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Inpatient PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
140_Ex_Inpatient_By_CateReport Id: 43735
Page 15 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Outpatient Utilization by Major Practice Category
Major Practice Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid Per
Unit PMPMVariancein PMPM
PMPMTrend
Cancer $1,590,957 6,172 $33.49 $17.23 5,286 $35.83 $15.78 9.14% -4.22%Orthopedic and Arthritic Conditions $1,410,380 2,247 $81.56 $15.27 3,057 $70.42 $17.94 -14.87% -16.51%Cardiology $1,182,830 2,862 $53.70 $12.81 2,416 $50.35 $10.14 26.33% -2.21%Gastroenterology $904,618 2,391 $49.16 $9.80 2,466 $54.07 $11.11 -11.85% 5.04%Gynecology $700,332 1,379 $66.01 $7.58 1,022 $64.09 $5.46 38.89% -2.57%Otolaryngology $559,177 1,047 $69.39 $6.05 846 $79.83 $5.63 7.63% 46.14%Psychiatry $407,974 667 $79.43 $4.42 606 $91.46 $4.62 -4.35% -1.34%Nephrology $398,193 7,391 $7.00 $4.31 1,954 $14.41 $2.35 83.77% -20.77%Endocrinology $382,805 1,905 $26.11 $4.15 1,109 $30.81 $2.85 45.55% 5.87%Chemical dependency $359,377 728 $64.14 $3.89 412 $57.21 $1.96 98.25% 76.82%Neurology $349,250 1,228 $36.97 $3.78 1,713 $35.67 $5.09 -25.74% -9.79%Urology $324,628 864 $48.83 $3.52 750 $54.33 $3.39 3.54% 17.73%Ophthalmology $236,559 471 $65.20 $2.56 416 $68.18 $2.36 8.39% 4.07%Hepatology $224,131 643 $45.28 $2.43 525 $44.01 $1.93 25.95% 17.96%Preventive and Administrative Care $210,958 293 $93.63 $2.28 335 $89.57 $2.50 -8.61% -6.17%Dermatology $192,116 350 $71.29 $2.08 443 $53.31 $1.97 5.78% 31.65%Pulmonology $144,613 654 $28.73 $1.57 577 $34.12 $1.64 -4.57% -14.21%Obstetrics $102,488 232 $57.38 $1.11 310 $65.98 $1.70 -34.87% -15.91%Isolated Signs/Symptoms $101,159 235 $56.04 $1.10 171 $65.05 $0.93 18.20% 26.44%Late effects/Complications $53,202 107 $64.49 $0.58 103 $42.13 $0.36 59.65% 11.54%Neonatology $51,783 59 $114.56 $0.56 137 $36.84 $0.42 33.77% 250.00%Hematology $48,360 984 $6.39 $0.52 927 $7.98 $0.62 -15.09% -24.64%Other $25,404 781 $4.23 $0.28 816 $8.99 $0.61 -55.03% -20.00%Infectious diseases $20,843 106 $25.54 $0.23 176 $31.17 $0.46 -50.56% -4.17%Total $9,982,138 33,796 $38.38 $108.09 26,572 $45.98 $101.81 6.16% -0.23%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2018 12:00:00 AMRun Date: 02/12/2018
© Copyright 2018 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 16 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient Utilization by Major Practice Category
Major Practice Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid Per
Unit PMPMVariancein PMPM
Orthopedic and Arthritic Conditions $1,666,372 3,149 $69.69 $18.29 3,154 $63.00 $16.56 10.44%Cancer $1,639,278 4,708 $45.85 $17.99 5,501 $32.77 $15.02 19.76%Cardiology $1,193,424 3,022 $52.00 $13.10 3,101 $48.99 $12.66 3.45%Gastroenterology $849,996 2,296 $48.74 $9.33 2,170 $49.87 $9.02 3.42%Gynecology $708,736 1,758 $53.09 $7.78 829 $57.08 $3.94 97.28%Nephrology $496,025 4,644 $14.06 $5.44 1,614 $17.72 $2.38 128.41%Psychiatry $408,318 686 $78.34 $4.48 761 $77.20 $4.90 -8.53%Neurology $381,450 1,274 $39.43 $4.19 1,370 $42.42 $4.84 -13.57%Otolaryngology $377,537 626 $79.40 $4.14 934 $64.74 $5.04 -17.80%Endocrinology $356,886 1,691 $27.80 $3.92 1,604 $37.35 $4.99 -21.57%Urology $272,490 716 $50.10 $2.99 691 $47.74 $2.75 8.74%Ophthalmology $223,920 364 $81.01 $2.46 371 $64.40 $1.99 23.38%Preventive and Administrative Care $221,219 292 $99.92 $2.43 408 $69.10 $2.35 3.45%Chemical dependency $200,295 535 $49.30 $2.20 571 $55.75 $2.65 -17.16%Hepatology $188,020 607 $40.78 $2.06 337 $42.26 $1.19 73.66%Pulmonology $166,382 629 $34.82 $1.83 833 $41.35 $2.87 -36.41%Dermatology $143,631 341 $55.54 $1.58 473 $51.06 $2.01 -21.65%Obstetrics $120,163 257 $61.46 $1.32 237 $71.68 $1.42 -7.01%Isolated Signs/Symptoms $79,692 159 $66.08 $0.87 230 $66.82 $1.28 -31.61%Hematology $63,075 1,697 $4.89 $0.69 787 $18.60 $1.22 -43.30%Late effects/Complications $47,467 100 $62.54 $0.52 97 $42.71 $0.35 50.42%Other $31,497 762 $5.44 $0.35 2 $87.48 $0.02 1,960.47%Infectious diseases $22,286 89 $33.07 $0.24 133 $50.25 $0.56 -56.20%Neonatology $15,030 13 $147.36 $0.16 161 $34.28 $0.46 -64.06%Total $9,873,188 30,416 $42.74 $108.34 26,371 $45.72 $100.47 7.84%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2018 12:00:00 AMRun Date: 02/12/2018
© Copyright 2018 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 17 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Outpatient PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Prior Aggregate
Report Period: 2/1/2018 12:00:00 ARun Date: 02/12/2018
© Copyright 2018 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 18 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Outpatient Utilization by Service Category
Service Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid per
Unit PMPMVariance in
PMPMPMPMTrend
Surgery $4,061,530 9,330 $56.56 $43.98 8,525 $61.12 $43.42 1.29% 6.46%
Other Treatments $1,807,156 12,856 $18.27 $19.57 8,548 $25.66 $18.28 7.07% -13.02%
Emergency Room $1,552,066 4,457 $45.25 $16.81 3,883 $42.81 $13.85 21.31% 10.01%
Radiology $1,172,080 4,436 $34.34 $12.69 3,313 $43.17 $11.92 6.48% -7.37%
Cardiovascular $523,571 93 $732.27 $5.67 92 $544.88 $4.19 35.41% 5.19%
Physical Therapy / Chiropractic $240,441 435 $71.75 $2.60 551 $73.16 $3.36 -22.47% -2.26%
Chemical Health $204,291 381 $69.68 $2.21 202 $72.05 $1.21 82.28% 45.39%
Lab $187,230 696 $34.98 $2.03 733 $43.44 $2.65 -23.63% -10.18%
Mental Health $177,094 63 $363.64 $1.92 83 $310.13 $2.14 -10.49% -2.54%
Observation/Non-Invasive Procedures $38,580 114 $44.14 $0.42 88 $56.13 $0.41 1.43% -68.66%
Pharmacy, Hospital or Clinic $18,099 936 $2.51 $0.20 554 $8.25 $0.38 -48.54% -52.38%
Total $9,982,138 33,796 $38.38 $108.09 26,572 $45.98 $101.81 6.16% -0.23%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Current Year Actual
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
160_Ex_Outpatient_by_CategoryReport Id: 43735
Page 19 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient Utilization by Service Category
Service Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid per
Unit PMPMVariance in
PMPM
Surgery $3,764,480 8,942 $55.44 $41.31 8,287 $61.13 $42.21 -2.14%
Other Treatments $2,050,536 10,851 $24.88 $22.50 8,499 $26.60 $18.84 19.43%
Emergency Room $1,392,672 4,061 $45.16 $15.28 3,904 $43.37 $14.11 8.31%
Radiology $1,248,459 3,932 $41.81 $13.70 3,099 $43.97 $11.35 20.66%
Cardiovascular $491,058 99 $650.41 $5.39 90 $517.12 $3.88 38.76%
Physical Therapy / Chiropractic $242,006 513 $62.18 $2.66 614 $67.69 $3.47 -23.37%
Lab $206,004 696 $38.97 $2.26 728 $42.41 $2.57 -12.10%
Mental Health $179,430 73 $325.64 $1.97 78 $303.49 $1.97 -0.01%
Chemical Health $138,124 243 $74.90 $1.52 196 $75.43 $1.23 23.09%
Observation/Non-Invasive Procedures $122,170 231 $69.53 $1.34 113 $53.81 $0.51 164.00%
Pharmacy, Hospital or Clinic $38,249 775 $6.50 $0.42 763 $4.99 $0.32 32.23%
Total $9,873,188 30,416 $42.74 $108.34 26,371 $45.72 $100.47 7.84%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Prior Year Actual
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
160_Ex_Outpatient_by_CategoryReport Id: 43735
Page 20 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Outpatient PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
160_Ex_Outpatient_by_CatReport Id: 43735
Page 21 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Pharmacy Trend Report
Group Actual Current YearMeasure Prior Year Current Year %Change Prior Year Current Year VarianceTotal Pharmacy PMPM (PL+ML) $106.94 $112.34 5.05% $86.63 $89.45 25.59%Rx Paid PMPM (Plan Paid) $95.27 $100.74 5.74% $76.54 $79.46 26.78%Total Pharmacy (PL+ML) $9,745,424 $10,374,949 6.46% Total Prescriptions 30 day Rx 118,962 120,847 1.58% Total Members w/Rx benefit 7,594 7,696 1.34% Average Ingredient Cost/Rx $78.36 $81.79 4.38% $72.09 $74.31 10.05%Average Generic Ingredient Cost/Rx $25.91 $24.16 -6.76% $22.60 $21.33 13.29%Average Brand Ingredient Cost/Rx $548.22 $650.02 18.57% $490.76 $586.77 10.78%Average Brand Ingredient Cost/Rx(Without Specialty Drugs) $320.78 $354.29 10.45% $287.31 $313.36 13.06%
Average Brand Ingredient Cost/Rx(Specialty Drugs only) $4,626.26 $5,347.56 15.59% $4,697.29 $5,128.96 4.26%
Average Rx/Member/Year 15.67 15.70 0.24% 13.89 13.88 13.15%Average Days Supply/Rx 26.48 26.43 -0.19% 26.25 26.26 0.63%Copay as Percent of Total Pharmacy 10.91% 10.33% -5.36% 11.64% 11.17% -7.54%Average Generic Copay/Rx $6.35 $6.47 1.76% $5.89 $5.89 9.87%Average Brand Copay/Rx $32.11 $32.54 1.35% $32.63 $35.29 -7.78%% Generic Use 89.96% 90.79% 0.93% 89.43% 90.63% 0.18%% Non-Formulary 2.34% 2.09% -10.58% 3.24% 2.78% -24.83%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Aggregate
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners178_Ex_Pharmacy_TrendReport Id: 43735
Page 22 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Pharmacy Utilization by Therapeutic Class
Current Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
PMPMTrend
Multiple Sclerosis 25.11% $1,339,493 $14.50 $5,798.67 0.03 10.45% $6.78 $5,768.76 0.01 113.92% -0.21%Chronic Inflammatory Disease 53.35% $1,277,194 $13.83 $1,946.94 0.09 53.52% $13.85 $2,128.11 0.08 -0.17% 15.06%Diabetes 62.72% $1,082,516 $11.72 $153.37 0.92 59.23% $9.62 $161.77 0.71 21.82% 10.25%Oncology 94.16% $656,370 $7.11 $851.32 0.10 93.66% $5.83 $706.98 0.10 21.93% 39.96%HIV 2.92% $654,097 $7.08 $1,591.48 0.05 3.61% $2.46 $1,661.58 0.02 187.57% 26.88%Stimulants 90.01% $520,190 $5.63 $161.85 0.42 86.02% $4.70 $159.65 0.35 19.79% -12.03%Asthma 32.77% $472,970 $5.12 $108.63 0.57 33.90% $4.52 $108.02 0.50 13.30% 10.82%OTHER 94.10% $404,250 $4.38 $53.02 0.99 92.99% $3.43 $49.53 0.83 27.78% 2.82%Dermatology 95.76% $289,375 $3.13 $95.13 0.40 94.17% $3.28 $118.07 0.33 -4.35% -12.81%Cystic Fibrosis 0.00% $184,735 $2.00 $5,598.02 0.00 6.67% $2.47 $4,921.40 0.01 -19.08% 173.97%Pulmonary Hypertension 0.00% $167,955 $1.82 $6,459.81 0.00 0.00% $0.43 $6,642.33 0.00 326.60% 18.18%Anticonvulsants 93.54% $158,632 $1.72 $41.16 0.50 91.98% $1.69 $54.21 0.37 1.72% -12.24%Hepatitis 79.31% $152,296 $1.65 $5,251.58 0.00 68.87% $0.96 $8,077.80 0.00 72.55% 34.15%Antidepressants 98.49% $151,611 $1.64 $10.52 1.87 98.66% $1.60 $10.78 1.78 2.34% 3.14%Ophthalmics 72.11% $146,363 $1.58 $85.39 0.22 74.49% $1.32 $67.18 0.24 19.76% 23.44%Contraceptives 94.50% $145,272 $1.57 $29.69 0.64 94.13% $1.86 $28.10 0.80 -15.57% 1.29%Inflammatory Bowel 26.06% $144,416 $1.56 $875.25 0.02 40.20% $1.26 $753.60 0.02 23.94% 3.31%Antipsychotics 91.54% $109,472 $1.19 $111.59 0.13 92.02% $0.94 $112.26 0.10 25.75% -7.03%Narcotic Analgesics 94.86% $105,462 $1.14 $32.10 0.43 95.37% $0.71 $26.21 0.33 60.89% -7.32%HRT 71.99% $104,970 $1.14 $60.75 0.22 69.86% $0.97 $62.63 0.19 16.93% 2.70%Anticoagulants 71.35% $92,592 $1.00 $123.95 0.10 70.66% $1.15 $115.67 0.12 -12.52% -3.85%Hypertension/Cardiac 99.81% $86,098 $0.93 $3.91 2.86 99.63% $0.92 $4.52 2.44 1.49% 1.09%Antibiotics 99.56% $83,861 $0.91 $14.60 0.75 99.72% $0.80 $12.88 0.74 14.14% -12.50%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 23 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Pharmacy Utilization by Therapeutic ClassCurrent Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
PMPMTrend
Migraines 93.82% $75,958 $0.82 $97.76 0.10 94.16% $0.63 $79.21 0.09 31.31% 7.89%Smoking Cessation 53.81% $73,913 $0.80 $194.00 0.05 51.06% $0.42 $198.99 0.03 88.71% 29.03%Cholesterol 99.43% $63,116 $0.68 $7.14 1.15 99.06% $0.72 $8.33 1.04 -5.38% -53.42%Ulcer/GERD 97.85% $62,057 $0.67 $11.31 0.71 97.65% $0.41 $8.96 0.55 64.93% -46.40%Androgens 72.87% $59,767 $0.65 $317.91 0.02 58.42% $0.52 $311.16 0.02 25.56% -13.33%Immunosuppressants 98.14% $59,737 $0.65 $185.52 0.04 92.20% $0.41 $132.97 0.04 57.82% 58.54%Immune Globulins 0.00% $42,265 $0.46 $3,251.12 0.00 0.00% $0.02 $3,258.90 0.00 1,835.56% 9.52%Over Active Bladder 90.49% $34,232 $0.37 $72.37 0.06 83.63% $0.35 $87.47 0.05 6.94% -26.00%Growth Hormones 0.00% $31,660 $0.34 $1,758.88 0.00 0.00% $1.21 $3,082.56 0.00 -71.65% 21.43%Erectile Dysfunction 79.87% $31,411 $0.34 $66.55 0.06 81.44% $0.22 $51.62 0.05 51.89% -44.26%Osteoporosis 94.19% $30,547 $0.33 $98.54 0.04 96.37% $0.33 $93.30 0.04 0.68% -58.75%Antiplatelets 84.69% $29,758 $0.32 $73.48 0.05 85.78% $0.22 $54.80 0.05 48.34% 3.23%Antivirals 95.11% $27,508 $0.30 $30.56 0.12 96.69% $0.27 $29.81 0.11 9.09% -16.67%Allergy 97.52% $27,350 $0.30 $9.30 0.38 97.53% $0.26 $10.03 0.32 11.89% 7.14%Biliary Cirrhosis 100.00% $18,719 $0.20 $301.92 0.01 100.00% $0.07 $238.00 0.00 211.43% 33.33%Thyroid 92.14% $18,516 $0.20 $3.56 0.67 88.95% $0.31 $5.97 0.62 -34.74% 5.26%Parkinsons Disease 96.07% $14,814 $0.16 $38.78 0.05 97.16% $0.16 $38.14 0.05 -1.65% 77.78%Infertility 46.15% $14,648 $0.16 $225.35 0.01 40.33% $0.30 $389.81 0.01 -47.21% -20.00%NSAIDS/COX-2 99.18% $13,086 $0.14 $8.94 0.19 99.86% $0.11 $8.39 0.16 23.40% -48.15%Hypnotics 98.56% $11,869 $0.13 $13.14 0.12 98.31% $0.12 $14.73 0.10 4.62% 0.00%Corticosteroids 98.63% $10,527 $0.11 $8.01 0.17 99.42% $0.22 $14.67 0.18 -47.37% 0.00%Antifungals 98.69% $10,315 $0.11 $19.25 0.07 99.76% $0.10 $20.42 0.06 10.47% -42.11%Antianxiety 99.87% $7,674 $0.08 $3.28 0.30 99.78% $0.09 $4.65 0.23 -6.47% 14.29%Alzheimers Disease 100.00% $3,823 $0.04 $46.63 0.01 98.42% $0.04 $32.88 0.01 14.95% -20.00%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 24 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Pharmacy Utilization by Therapeutic ClassCurrent Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
PMPMTrend
Blood Modiefiers 0.00% $0 $0.00 $0.00 0.00 0.00% $0.00 $0.00 0.00 0.00% -100.00%
Total 180.75% $9,303,463 $100.74 $76.99 1.31 180.06% $79.06 $68.37 13.88 27.42% 5.74%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
SPECIALTY 15.40% $4,010,978 $43.43 $5,148.88 0.10 8.08% $33.42 $4,992.44 0.08 29.96% 16.75%
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 25 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic Class
Prior Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
Multiple Sclerosis 23.17% $1,324,418 $14.53 $5,383.81 0.032 11.75% $6.34 $5,291.19 0.014 129.28%Chronic Inflammatory Disease 56.30% $1,095,596 $12.02 $1,703.88 0.085 70.84% $11.10 $1,206.14 0.110 8.30%Diabetes 64.36% $968,679 $10.63 $144.41 0.883 59.68% $8.90 $153.45 0.696 19.45%Stimulants 87.33% $583,303 $6.40 $189.51 0.405 83.72% $4.95 $173.78 0.342 29.29%HIV 4.46% $508,727 $5.58 $1,417.07 0.047 0.00% $0.00 $0.00 0.000 0.00%Oncology 96.07% $462,506 $5.08 $605.37 0.101 89.76% $5.29 $1,064.58 0.060 -4.10%Asthma 32.13% $420,623 $4.62 $99.44 0.557 32.41% $4.28 $104.52 0.492 7.74%OTHER 92.32% $387,809 $4.26 $53.29 0.958 92.09% $3.55 $52.51 0.812 19.74%Dermatology 94.03% $327,034 $3.59 $111.50 0.386 92.38% $3.36 $117.83 0.342 6.83%Anticonvulsants 92.15% $178,201 $1.96 $48.57 0.483 91.51% $1.65 $54.06 0.367 18.44%Antidepressants 98.08% $144,744 $1.59 $10.37 1.838 98.19% $1.83 $12.81 1.712 -13.10%Contraceptives 94.61% $141,653 $1.55 $27.94 0.668 93.40% $1.92 $28.06 0.820 -18.93%Pulmonary Hypertension 0.00% $140,715 $1.54 $5,863.11 0.003 95.96% $0.46 $284.94 0.019 236.94%Inflammatory Bowel 4.71% $137,895 $1.51 $811.15 0.022 9.82% $1.19 $699.92 0.020 26.88%Cholesterol 94.72% $132,999 $1.46 $15.02 1.166 94.48% $1.51 $17.08 1.059 -3.22%Ophthalmics 69.48% $116,994 $1.28 $72.71 0.212 71.27% $1.24 $65.15 0.228 3.83%Antipsychotics 91.98% $116,694 $1.28 $111.35 0.138 90.02% $1.19 $145.01 0.099 7.43%Ulcer/GERD 97.47% $113,975 $1.25 $21.67 0.693 96.82% $0.61 $13.31 0.549 105.42%Hepatitis 71.88% $112,486 $1.23 $3,515.20 0.004 56.65% $1.63 $11,651.46 0.002 -24.43%Narcotic Analgesics 95.64% $112,282 $1.23 $32.40 0.456 95.28% $0.85 $28.32 0.359 45.36%HRT 65.26% $101,162 $1.11 $59.16 0.225 59.02% $1.09 $62.56 0.209 1.80%Antibiotics 99.71% $94,865 $1.04 $16.42 0.761 99.64% $0.97 $15.28 0.758 7.82%Anticoagulants 76.02% $94,608 $1.04 $113.44 0.110 77.65% $0.94 $95.72 0.118 9.93%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic ClassPrior Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
Hypertension/Cardiac 99.70% $84,162 $0.92 $3.81 2.907 99.28% $1.00 $4.86 2.456 -7.23%Osteoporosis 91.24% $73,038 $0.80 $164.13 0.059 96.99% $0.24 $61.22 0.046 240.84%Migraines 89.88% $68,958 $0.76 $95.64 0.095 91.94% $0.64 $81.90 0.094 17.45%Androgens 55.25% $67,999 $0.75 $375.68 0.024 55.93% $0.49 $315.57 0.019 52.85%Cystic Fibrosis 0.00% $66,631 $0.73 $1,448.50 0.006 6.07% $1.49 $3,663.44 0.005 -50.86%Smoking Cessation 53.82% $56,391 $0.62 $165.86 0.045 48.35% $0.35 $181.61 0.023 76.53%Erectile Dysfunction 44.44% $55,351 $0.61 $146.43 0.050 0.00% $0.51 $163.02 0.038 18.11%Over Active Bladder 86.68% $45,295 $0.50 $92.82 0.064 80.04% $0.43 $104.98 0.049 16.19%Immune Globulins 0.00% $38,367 $0.42 $3,197.29 0.002 0.00% $0.00 $0.00 0.000 0.00%Immunosuppressants 91.34% $37,028 $0.41 $133.68 0.036 86.84% $0.52 $166.51 0.038 -21.97%Antivirals 90.82% $33,215 $0.36 $39.59 0.110 80.28% $2.50 $242.62 0.123 -85.40%Antiplatelets 82.06% $27,937 $0.31 $66.83 0.055 87.10% $0.18 $44.84 0.049 66.44%Blood Modiefiers 0.00% $26,581 $0.29 $4,430.17 0.001 0.00% $0.26 $3,328.81 0.001 10.33%Growth Hormones 0.00% $25,815 $0.28 $1,843.92 0.002 0.00% $0.99 $3,006.40 0.004 -71.42%Allergy 97.97% $25,447 $0.28 $9.06 0.370 96.70% $0.30 $11.32 0.317 -6.70%NSAIDS/COX-2 98.77% $24,281 $0.27 $15.67 0.204 99.66% $0.19 $13.52 0.167 41.62%Infertility 40.63% $18,386 $0.20 $287.28 0.008 38.96% $0.37 $422.80 0.010 -44.92%Antifungals 98.51% $17,646 $0.19 $32.80 0.071 99.66% $0.10 $21.55 0.058 87.28%Thyroid 90.88% $17,237 $0.19 $3.47 0.654 87.87% $0.32 $6.09 0.622 -40.08%Biliary Cirrhosis 100.00% $13,224 $0.15 $330.61 0.005 100.00% $0.08 $283.89 0.003 90.91%Hypnotics 98.67% $12,152 $0.13 $11.53 0.139 97.80% $0.16 $17.62 0.110 -17.81%Corticosteroids 99.11% $10,329 $0.11 $7.69 0.177 99.36% $0.26 $18.58 0.171 -57.18%Parkinsons Disease 99.02% $8,108 $0.09 $19.83 0.054 97.08% $0.16 $35.22 0.055 -44.50%Antianxiety 99.82% $5,964 $0.07 $2.75 0.286 99.73% $0.08 $4.45 0.226 -22.05%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 27 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic ClassPrior Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
Alzheimers Disease 100.00% $4,425 $0.05 $83.50 0.007 95.79% $0.04 $33.46 0.013 31.89%
Total 180.75% $8,681,936 $95.27 $72.98 15.665 180.06% $76.51 $66.12 13.886 24.52%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
SPECIALTY 14.61% $3,389,709 $37.20 $4,586.89 0.097 7.83% $28.02 $4,576.01 0.073 32.75%
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 28 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Top 10 Pharmacy PMPM by Therapeutic Class
All Packages/All Sites YTD Qtrly
C P Prior YearCurrent Year C Current Aggregate P Prior Aggregate
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 29 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Pharmacy Channel Management
All Packages/All Sites YTD Qtrly
Utilization and Trend Aggregate
Percent Total Rx Prior Year Current Year % Change Prior Year Current YearCurrent Year
Variance
% Retail 41.30% 40.62% -1.64% 42.62% 41.70% -2.58%
% Extended Retail, 3-month Rx 56.45% 57.25% 1.42% 55.73% 56.85% 0.70%
% Mail Order 1.63% 1.49% -8.86% 1.12% 0.88% 69.82%
% Specialty 0.62% 0.64% 3.77% 0.53% 0.58% 11.37%
Utilization and Trend
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners Report Id: 43735179_Ex_Pharmacy_by_Class
Page 30 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Pharmacy Channel Management
Prior Year Actual Aggregate
Chain Name % Total Rx Total Rx % Paid Paid % Total Rx % PaidVariance in
% PaidCVS PHARMACARE SPECIALTY PHARM 0.53% 627 34.08% $2,958,925 0.40% 29.05% 17.32%
WALGREENS 33.78% 40,187 21.91% $1,902,409 30.60% 21.11% 3.78%
HEALTHPARTNERS MAILORDER 12.56% 14,941 8.48% $736,383 8.88% 6.88% 23.25%
HEALTHPARTNERS 9.25% 11,003 7.02% $609,400 5.42% 4.57% 53.58%
TARGET 12.85% 15,285 5.90% $512,293 13.65% 7.90% -25.28%
Total 68.97% 82,043 77.40% $6,719,410 58.95% 69.51% 11.34%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Current Year Actual Aggregate
Chain Name % Total Rx Total Rx % Paid Paid % Total Rx % PaidVariance in
% PaidPaid
TrendCVS PHARMACARE SPECIALTY PHARM 0.50% 609 33.05% $3,075,143 0.42% 31.28% 5.67% -3.02%
WALGREENS 34.32% 41,480 20.09% $1,869,078 31.67% 20.04% 0.27% -8.31%
HEALTHPARTNERS MAILORDER 12.62% 15,254 8.15% $758,697 8.07% 5.86% 39.20% -3.89%
HEALTHPARTNERS 8.97% 10,835 6.45% $599,658 4.99% 4.35% 48.13% -8.12%
TARGET 12.16% 14,695 5.51% $512,895 13.15% 7.01% -21.34% -6.61%
Total 68.58% 82,873 73.26% $6,815,472 58.30% 68.53% 9.13% -29.95%
Top 5 Pharmacy Chains
Report Period: 2/1/2018 12:00:00 Run Date: 02/12/2018
© Copyright 2018 HealthPartners Report Id: 43735179_Ex_Pharmacy_by_Class
Page 31 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Pharmacy Top 20 Drugs by Cost
Drug Therapeutic Brand / Rx Claims Paid / RxName Class Generic Prior Current %Change Prior Current %Change Prior Current %ChangeHumira* Chronic Inflammatory DisBrand 140 138 -1.43% $602,565 $649,631 7.81% $4,304.03 $4,707.47 9.37%Enbrel* Chronic Inflammatory DisBrand 80 94 17.50% $308,477 $382,245 23.91% $3,855.97 $4,066.44 5.46%Humalog Diabetes Brand 669 671 0.30% $323,298 $345,537 6.88% $483.26 $514.96 6.56%Rebif* Multiple Sclerosis Brand 50 48 -4.00% $305,781 $325,754 6.53% $6,115.62 $6,786.54 10.97%Adderall Stimulants Generic 964 948 -1.66% $259,259 $243,779 -5.97% $268.94 $257.15 -4.38%Tecfidera* Multiple Sclerosis Brand 26 32 23.08% $160,290 $219,754 37.10% $6,165.02 $6,867.30 11.39%Glatopa* Multiple Sclerosis Generic 57 55 -3.51% $223,093 $214,747 -3.74% $3,913.91 $3,904.50 -0.24%Advair Asthma Brand 580 584 0.69% $193,638 $208,504 7.68% $333.86 $357.03 6.94%Gilenya* Multiple Sclerosis Brand 33 28 -15.15% $220,534 $207,445 -5.94% $6,682.85 $7,408.76 10.86%Victoza Diabetes Brand 249 308 23.69% $148,653 $191,467 28.80% $597.00 $621.65 4.13%Copaxone* Multiple Sclerosis Brand 40 29 -27.50% $230,625 $185,588 -19.53% $5,765.62 $6,399.58 11.00%Basaglar Diabetes Brand 5 or Under 779 0.00% $0 $169,189 0.00% $0.00 $217.19 0.00%Aubagio* Multiple Sclerosis Brand 17 24 41.18% $98,981 $145,754 47.25% $5,822.41 $6,073.06 4.30%Ibrance* Oncology Brand 11 15 36.36% $94,364 $142,958 51.50% $8,578.52 $9,530.55 11.10%Kalydeco* Cystic Fibrosis Brand 5 or Under 6 0.00% $0 $142,106 0.00% $0.00 $23,684.27 0.00%Methylphenidate Stimulants Generic 843 773 -8.30% $139,735 $135,503 -3.03% $165.76 $175.30 5.76%Truvada HIV Brand 83 88 6.02% $119,500 $134,543 12.59% $1,439.76 $1,528.89 6.19%Xyrem* OTHER Brand 12 12 0.00% $121,218 $128,982 6.40% $10,101.51 $10,748.50 6.40%Letairis* Pulmonary Hypertension Brand 12 13 8.33% $104,155 $120,411 15.61% $8,679.57 $9,262.38 6.71%Imatinib* Oncology Generic 22 23 4.55% $155,575 $115,275 -25.90% $7,071.60 $5,011.98 -29.13%
Total 3,888 4,668 20.06% $3,809,741 $4,409,171 15.73% $979.87 $944.55 -3.60%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR* Specialty Drug
Report Period: 2/1/2018 12:Run Date: 02/12/2018
© Copyright 2018 HealthPartners Report Id: 43735180_Ex_Pharmacy_Top_20
Page 32 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Pharmacy Top 20 Drugs by Volume
Drug Therapeutic Brand / Rx Claims Paid / RxName Class Generic Prior Current %Change Prior Current %Change Prior Current %ChangeAtorvastatin Cholesterol Generic 4,333 4,702 8.52% $1,926 $1,166 -39.44% $0.44 $0.25 -43.18%Levothyroxine Thyroid Generic 4,452 4,683 5.19% $12,815 $12,115 -5.46% $2.88 $2.59 -10.07%Lisinopril Hypertension/Cardiac Generic 4,251 4,190 -1.43% $501 $463 -7.64% $0.12 $0.11 -8.33%Omeprazole Ulcer/GERD Generic 3,165 3,260 3.00% $1,137 $723 -36.40% $0.36 $0.22 -38.89%Metformin Diabetes Generic 2,998 3,135 4.57% $1,966 $1,568 -20.23% $0.66 $0.50 -24.24%Amlodipine Hypertension/Cardiac Generic 2,575 2,692 4.54% $254 $387 52.42% $0.10 $0.14 40.00%Metoprolol Hypertension/Cardiac Generic 2,301 2,618 13.78% $9,417 $8,540 -9.30% $4.09 $3.26 -20.29%Sertraline Antidepressants Generic 2,344 2,567 9.51% $687 $632 -8.12% $0.29 $0.25 -13.79%Simvastatin Cholesterol Generic 2,576 2,168 -15.84% $239 $131 -45.12% $0.09 $0.06 -33.33%Hydrochlorothiazide Hypertension/Cardiac Generic 2,335 2,081 -10.88% $170 $133 -21.55% $0.07 $0.06 -14.29%Bupropion Antidepressants Generic 1,951 2,058 5.48% $20,562 $18,079 -12.08% $10.54 $8.78 -16.70%Fluticasone Allergy Generic 1,849 1,875 1.41% $1,785 $880 -50.67% $0.97 $0.47 -51.55%Losartan Hypertension/Cardiac Generic 1,538 1,868 21.46% $421 $465 10.38% $0.27 $0.25 -7.41%Fluoxetine Antidepressants Generic 1,760 1,817 3.24% $1,524 $763 -49.91% $0.87 $0.42 -51.72%Citalopram Antidepressants Generic 1,728 1,612 -6.71% $204 $249 21.77% $0.12 $0.15 25.00%Trazodone Antidepressants Generic 1,543 1,544 0.06% $1,111 $3,571 221.25% $0.72 $2.31 220.83%Gabapentin Anticonvulsants Generic 1,313 1,444 9.98% $4,915 $5,304 7.92% $3.74 $3.67 -1.87%Ventolin Asthma Brand 1,342 1,421 5.89% $33,425 $41,237 23.37% $24.91 $29.02 16.50%Lisinopril-Hctz Hypertension/Cardiac Generic 1,372 1,364 -0.58% $146 $175 19.91% $0.11 $0.13 18.18%Atenolol Hypertension/Cardiac Generic 1,810 1,326 -26.74% $205 $171 -16.62% $0.11 $0.13 18.18%
Total 47,536 48,425 1.87% $93,412 $96,755 3.58% $1.97 $2.00 1.68%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Report Period: 2/1/2018 12:Run Date: 02/12/2018
© Copyright 2018 HealthPartners Report Id: 43735180_Ex_Pharmacy_Top_20
Page 33 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Tier Utilization
Utilization Category Tier 1 Tier 2 Tier 3 Out of Network Total
Professional 17,898,926.48 3,303,804.74 0 204,605.7 $21,407,337
Hospital IP 5,267,540.73 2,693,791.56 0 182,544.06 $8,143,876
Hospital OP 7,253,522.17 3,036,128.24 0 379,943.77 $10,669,594
Pharmacy 9,959,524.47 0 0 0 $9,959,524
DME, Transportation, Other 1,267,487.08 104,158.21 0 15,503.99 $1,387,149
Preventive/Accidental Dental 0 0 0 0 $0
Total 41,647,000.93 9,137,882.75 0 782,597.52 $51,567,481
Percent of Claims 80.76% 17.72% 0.00% 1.52% 100.00%
Members 7,506 2,479 0 215 10,200
Percent Members 73.59% 24.30% 0.00% 2.11% 100.00%
All Packages/All Sites YTD Qtrly
Notes: Members will be counted more than once if they incurred services in multiple networks.Members with only out-of-network claims = 2Claims include IBNRSome benefit plans do not utilize all tier levles. In these cases, there would be no claims dollars.
Current Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
190_Ex_Tier_Network_UtilizationReport Id: 43735
Page 34 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Tier Utilization
Utilization Category Tier 1 Tier 2 Tier 3 Out of Network Total
Professional 17,171,776.47 3,923,909.71 0 189,071.57 $21,284,758
Hospital IP 3,975,670.28 5,101,403.86 0 90,154.95 $9,167,229
Hospital OP 6,419,771.21 3,894,143.78 0 248,430.13 $10,562,345
Pharmacy 9,298,655.22 0 0 0 $9,298,655
DME, Transportation, Other 995,947.46 128,875.77 0 10,525.8 $1,135,349
Preventive/Accidental Dental 0 0 0 0 $0
Total 37,861,820.64 13,048,333.12 0 538,182.46 $51,448,336
Percent of Claims 73.59% 25.36% 0.00% 1.05% 100.00%
Members 7,437 2,634 0 223 10,294
Percent Members 72.25% 25.59% 0.00% 2.17% 100.00%
All Packages/All Sites YTD Qtrly
Notes: Members will be counted more than once if they incurred services in multiple networks.Members with only out-of-network claims = 2Claims include IBNRSome benefit plans do not utilize all tier levels. In these cases, there would be no claims dollars.
Prior Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
190_Ex_Tier_Network_UtilizationReport Id: 43735
Page 35 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Monthly Summary - Contracts
All Packages/All Sites YTD Qtrly
Member and contract counts are as of the 15th of each month and include retroactive adjustments.
Period Members Total Single Family
Jan 2017 7,657 3,752 2,274 1,478
Feb 2017 7,617 3,745 2,276 1,469
Mar 2017 7,669 3,775 2,301 1,474
Apr 2017 7,697 3,782 2,298 1,484
May 2017 7,710 3,787 2,298 1,489
Jun 2017 7,711 3,790 2,297 1,493
Jul 2017 7,707 3,797 2,302 1,495
Aug 2017 7,716 3,802 2,310 1,492
Sep 2017 7,718 3,807 2,314 1,493
Oct 2017 7,701 3,804 2,314 1,490
Nov 2017 7,714 3,801 2,302 1,499
Dec 2017 7,735 3,813 2,317 1,496
Total 92,352 45,455 27,603 17,852
Average 7,696 3,788 2,300 1,488
Current Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00:00 AM © Copyright 2018 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 36 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Monthly Summary - Contracts
All Packages/All Sites YTD Qtrly
Member and contract counts are as of the 15th of each month and include retroactive adjustments.
Period Members Total Single Family
Jan 2016 7,572 3,740 2,273 1,467
Feb 2016 7,559 3,737 2,272 1,465
Mar 2016 7,595 3,749 2,276 1,473
Apr 2016 7,610 3,767 2,295 1,472
May 2016 7,595 3,762 2,297 1,465
Jun 2016 7,626 3,768 2,297 1,471
Jul 2016 7,576 3,750 2,289 1,461
Aug 2016 7,581 3,758 2,300 1,458
Sep 2016 7,589 3,760 2,300 1,460
Oct 2016 7,615 3,751 2,281 1,470
Nov 2016 7,611 3,753 2,288 1,465
Dec 2016 7,599 3,740 2,274 1,466
Total 91,128 45,035 27,442 17,593
Average 7,594 3,753 2,287 1,466
Prior Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00:00 AM © Copyright 2018 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 37 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Monthly Summary - Revenue and Claims
All Packages/All Sites YTD Qtrly
Revenue is shown on an earned premium basis and includes retroactive adjustments. Revenue only includes medical premiums;special charges are not included.
Period Members Total PMPM Total PMPM Care Ratio
Jan 2017 7,657 $4,692,231 $612.80 $4,376,379 $571.55
Feb 2017 7,617 $4,676,857 $614.00 $3,781,285 $496.43
Mar 2017 7,669 $4,705,964 $613.63 $4,572,238 $596.20
Apr 2017 7,697 $4,723,555 $613.69 $4,109,473 $533.91
May 2017 7,710 $4,730,577 $613.56 $4,570,626 $592.82
Jun 2017 7,711 $4,740,383 $614.76 $4,078,647 $528.94
Jul 2017 7,707 $4,747,597 $616.01 $4,120,544 $534.65
Aug 2017 7,716 $4,753,041 $616.00 $4,582,387 $593.88
Sep 2017 7,718 $4,759,625 $616.69 $4,502,074 $583.32
Oct 2017 7,701 $4,754,146 $617.34 $5,203,131 $675.64
Nov 2017 7,714 $4,761,009 $617.19 $4,455,515 $577.59
Dec 2017 7,735 $4,774,368 $617.24 $5,436,830 $702.89
Total 92,352 $56,819,352 $53,789,129 94.67%
Average 7,696 $4,734,946 $615.24 $4,482,427 $582.44
Claims include IBNR and pooling charges
Revenue ClaimsCurrent Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00:00 AM © Copyright 2018 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 38 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Monthly Summary - Revenue and Claims
All Packages/All Sites YTD Qtrly
Revenue is shown on an earned premium basis and includes retroactive adjustments. Revenue only includes medical premiums;special charges are not included.
Period Members Total PMPM Total PMPM Care Ratio
Jan 2016 7,572 $4,488,443 $592.77 $3,541,703 $467.74
Feb 2016 7,559 $4,481,907 $592.92 $4,239,044 $560.79
Mar 2016 7,595 $4,496,974 $592.10 $4,380,492 $576.76
Apr 2016 7,610 $4,510,417 $592.70 $4,573,015 $600.92
May 2016 7,595 $4,500,083 $592.51 $5,201,060 $684.80
Jun 2016 7,626 $4,512,336 $591.70 $4,369,435 $572.97
Jul 2016 7,576 $4,486,043 $592.14 $4,531,363 $598.12
Aug 2016 7,581 $4,490,452 $592.33 $4,468,789 $589.47
Sep 2016 7,589 $4,494,219 $592.20 $4,223,935 $556.59
Oct 2016 7,615 $4,498,828 $590.78 $4,081,577 $535.99
Nov 2016 7,611 $4,492,572 $590.27 $4,264,854 $560.35
Dec 2016 7,599 $4,484,270 $590.11 $5,690,375 $748.83
Total 91,128 $53,936,542 $53,565,640 99.31%
Average 7,594 $4,494,712 $591.88 $4,463,803 $587.81
Claims include IBNR and pooling charges
Revenue ClaimsPrior Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00:00 AM © Copyright 2018 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 39 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Contract Distribution
All Packages/All Sites YTD Qtrly
C PCurrent Year Prior Year
Average Members per Ramsey County [12900] Prior Year Aggregate
All Family Type Contracts: 3.63 3.62 3.42
All Contracts: 2.03 2.02 2.05
C Current Aggregate P Prior Aggregate
Run Date: 02/12/2018Report Period: 2/1/2018 12:00:00 AM © Copyright 2018 HealthPartners Report Id: 43735
200_Ex_Monthly_Summary
Page 40 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Demographics Summary
Member Months Average % of Total Aggregate % of Total
Female 50,959 4,247 55.18% 53.24%
Male 41,393 3,449 44.82% 46.76%
Total 92,352 7,696 100.00% 100.00%
All Packages/All Sites YTD Qtrly
Current Year Gender Distribution
Current Year Relationship Distribution
Member Months Average % of Total Aggregate % of Total
Policyholder 44,949 3,746 48.67% 48.66%
Dependent 47,403 3,950 51.33% 51.34%
Total 92,352 7,696 100.00% 100.00%
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
210_Ex_Demographics_SummaryReport Id: 43735
Page 41 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Demographics Summary
Member Months Average % of Total Aggregate % of Total
Female 50,380 4,198 55.28% 53.54%
Male 40,748 3,396 44.72% 46.46%
Total 91,128 7,594 100.00% 100.00%
All Packages/All Sites YTD Qtrly
Prior Year Gender Distribution
Prior Year Relationship Distribution
Member Months Average % of Total Aggregate % of Total
Policyholder 44,626 3,719 48.97% 48.81%
Dependent 46,502 3,875 51.03% 51.19%
Total 91,128 7,594 100.00% 100.00%
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
210_Ex_Demographics_SummaryReport Id: 43735
Page 42 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Demographics: Detail
Age RangeFemale
Policyholder DependentMale
Policyholder Dependent Total % of Total
Under 1 0 29 0 31 60 0.78%
1 - 4 0 138 0 183 321 4.15%
5 - 9 0 242 0 223 465 6.01%
10 - 14 0 270 1 272 543 7.02%
15 - 19 2 324 1 296 623 8.05%
20 - 24 23 306 18 277 624 8.07%
25 - 29 114 78 82 60 334 4.32%
30 - 34 197 66 147 35 445 5.75%
35 - 39 252 85 159 88 584 7.55%
40 - 44 237 92 151 93 573 7.41%
45 - 49 256 87 192 81 616 7.96%
50 - 54 321 97 224 90 732 9.46%
55 - 59 363 98 230 95 786 10.16%
60 - 64 421 76 238 112 847 10.95%
65 Over 77 12 62 31 182 2.35%
Total 2,263 2,000 1,505 1,967 7,735 100.00%
All Packages/All Sites YTD Qtrly
Counts shown are for the last month in the reporting period.
Current Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
220_Ex_Demographics_DetailReport Id: 43735
Page 43 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Demographics: Detail
Age RangeFemale
Policyholder DependentMale
Policyholder Dependent Total % of Total
Under 1 0 23 0 43 66 0.87%
1 - 4 0 132 0 171 303 3.99%
5 - 9 0 265 0 227 492 6.47%
10 - 14 0 252 1 266 519 6.83%
15 - 19 2 309 0 308 619 8.15%
20 - 24 9 295 12 268 584 7.69%
25 - 29 100 78 65 51 294 3.87%
30 - 34 195 58 146 36 435 5.72%
35 - 39 261 85 138 85 569 7.49%
40 - 44 226 94 153 88 561 7.38%
45 - 49 268 89 186 77 620 8.16%
50 - 54 319 96 234 89 738 9.71%
55 - 59 369 94 230 103 796 10.48%
60 - 64 423 64 246 107 840 11.05%
65 Over 73 11 46 33 163 2.15%
Total 2,245 1,945 1,457 1,952 7,599 100.00%
All Packages/All Sites YTD Qtrly
Counts shown are for the last month in the reporting period.
Prior Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
220_Ex_Demographics_DetailReport Id: 43735
Page 44 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Age Distribution
All Packages/All Sites YTD Qtrly
CG Current Year CA Current Aggregate PG Prior Year PA Prior Aggregate
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
220_Ex_Demographics_DeReport Id: 43735
Page 45 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Cost Savings Detail
All Packages/All Sites YTD Qtrly
COB Savings
COB SavingsWorkers Compensation $25,558 $0 $580 $0 $27 $0 $26,165No-Fault $1,365 $0 $733 $0 $1,458 $0 $3,556Third Party Liability $0 $0 $0 $0 $0 $0 $0Occupational Health $0 $0 $0 $0 $0 $0 $0Other Insurance: Under 65 $484,484 $489,179 $3,201,076 $0 $45,789 $0 $4,220,527Other Insurance: Over 65 $187,348 $8,840 $400,070 $0 $12,952 $0 $609,210Total: $698,756 $498,019 $3,602,458 $0 $60,225 $0 $4,859,459
Benefit Design Savings
Benefit Design SavingsDeductibles $220,863 $4,470 $15,760 $0 $8,633 $0 $249,726Copayments/Coinsurance $1,364,159 $87,648 $379,186 $1,071,487 $190,505 $0 $3,092,986Other Member Liability $0 $326 $2,904 $0 $100 $0 $3,330Total: $1,585,022 $92,445 $397,850 $1,071,487 $199,238 $0 $3,346,042
Other Savings
Other SavingsUCR Limits $180,398 $0 $0 $0 $0 $0 $180,398Ineligible Services $49,774 $162 $4,855 $0 $37,732 $0 $92,524Total: $230,173 $162 $4,855 $0 $37,732 $0 $272,922
Provider Discount Savings
Provider Discount SavingsNegotiated Discounts $12,469,348 $6,919,820 $14,420,923 $10,771,700 $695,507 $0 $45,277,298Total: $12,469,348 $6,919,820 $14,420,923 $10,771,700 $695,507 $0 $45,277,298
Professional Hospital IP Hospital OP Pharmacy Other Dental TotalBilled Charge $34,630,142 $14,939,173 $28,264,281 $21,030,207 $2,279,979 $0 $101,143,782
Grand Total Savings $14,983,299 $7,510,445 $18,426,087 $11,843,187 $992,702 $0 $53,755,720
Claims$19,995,217 $7,556,020 $9,982,138 $9,303,463 $1,294,570 $0 $48,131,408
(billed charge - grand total savings + tax)
Provider Tax $348,374 $127,293 $143,944 $116,442 $7,293 $0 $743,346
Savings Percentage 43.27% 50.27% 65.19% 56.32% 43.54% 0.00% 53.15%(based on billed charge)
Note: Claims do not include IBNR
Current Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
310_Ex_Cost_Savings_DetailReport Id: 43735
Page 46 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Cost Savings Detail
All Packages/All Sites YTD Qtrly
COB Savings
COB SavingsWorkers Compensation $8,293 $0 $0 $0 $1,364 $0 $9,657No-Fault $922 $0 $6,829 $0 $4,058 $0 $11,809Third Party Liability $0 $0 $0 $0 $0 $0 $0Occupational Health $0 $0 $0 $0 $0 $0 $0Other Insurance: Under 65 $430,705 $542,048 $1,067,327 $0 $25,581 $0 $2,065,662Other Insurance: Over 65 $186,050 $968 $648,993 $0 $10,546 $0 $846,558Total: $625,970 $543,017 $1,723,149 $0 $41,549 $0 $2,933,685
Benefit Design Savings
Benefit Design SavingsDeductibles $223,487 $2,391 $13,868 $0 $10,087 $0 $249,833Copayments/Coinsurance $1,208,578 $82,178 $397,730 $1,063,489 $185,626 $0 $2,937,600Other Member Liability $716 $71 $32,534 $0 $0 $0 $33,322Total: $1,432,781 $84,641 $444,132 $1,063,489 $195,713 $0 $3,220,755
Other Savings
Other SavingsUCR Limits $34,562 $0 $0 $0 $0 $0 $34,562Ineligible Services $42,501 $145 -$18,816 $0 $35,340 $0 $59,170Total: $77,063 $145 -$18,816 $0 $35,340 $0 $93,733
Provider Discount Savings
Provider Discount SavingsNegotiated Discounts $11,769,785 $7,797,704 $13,733,460 $9,335,989 $725,033 $0 $43,361,972Total: $11,769,785 $7,797,704 $13,733,460 $9,335,989 $725,033 $0 $43,361,972
Professional Hospital IP Hospital OP Pharmacy Other Dental TotalBilled Charge $33,460,569 $16,793,596 $25,612,509 $18,972,423 $2,046,691 $0 $96,885,787
Grand Total Savings $13,905,600 $8,425,507 $15,881,925 $10,399,478 $997,635 $0 $49,610,145
Claims$19,894,723 $8,506,323 $9,873,188 $8,681,936 $1,056,178 $0 $48,012,348
(billed charge - grand total savings + tax)
Provider Tax $339,754 $138,235 $142,605 $108,991 $7,122 $0 $736,706
Savings Percentage 41.56% 50.17% 62.01% 54.81% 48.74% 0.00% 51.20%(based on billed charge)
Note: Claims do not include IBNR
Prior Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
310_Ex_Cost_Savings_DetailReport Id: 43735
Page 47 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Top 25 Medical Providers - All Service Categories
Provider Claims ClaimantsHEALTHPARTNERS MEDICAL GROUP $5,024,668 3,613
REGIONS HOSPITAL-RAD/ACUTE/SLEEP $3,443,124 854
CVS/SPECIALTY #02921 $3,075,143 68
UNITED HOSPITAL $1,224,243 233
HEALTHEAST ST JOHNS & MIDWAY $1,058,010 285
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW WEST $963,797 221
MAYO CLINIC ROCHESTER $813,953 97
HEALTHPARTNERS MAIL ORDER PHARMACY $758,697 502
MAYO CLINIC HOSPITAL-ROCHESTER $675,186 40
CHILDRENS HEALTH CARE-MPLS $629,099 102
PARK NICOLLET CLINIC $614,390 384
HEALTHEAST WOODWINDS HOSPITAL $584,459 169
CVS PHARMACY # $569,310 1,281
FAIRVIEW SOUTHDALE HOSPITAL $525,198 71
CHILDRENS HEALTH CARE-ST PAUL $502,878 165
ABBOTT NORTHWESTERN HOSPITAL $492,528 140
HEALTHPARTNERS SAME DAY SURG CENTER $469,661 267
HEALTHEAST ST JOSEPHS $469,078 80
SUMMIT ORTHOPEDICS,LTD $421,249 280
PARK NICOLLET METHODIST HOSPITAL-ACUTE $416,143 79
MERCY HOSPITAL $395,194 87
FAIRVIEW SPECIALTY SERVICES PHARMACY $351,769 12
FAIRVIEW PHARMACY SERVICES LLC-HH $345,856 5 or under
All Packages/All Sites YTD Qtrly
Current Year by Dollars Paid
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 48 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Top 25 Medical Providers - All Service CategoriesProvider Claims ClaimantsMINNESOTA GASTROENTEROLOGY PA $343,259 246
SUMMIT ORTHOPEDICS,LTD-BUNDLED $323,875 14
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 49 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service Categories
Provider Claims ClaimantsHEALTHPARTNERS MEDICAL GROUP $4,809,334 3,695
REGIONS HOSPITAL-RAD/ACUTE/SLEEP $3,418,292 962
CVS/SPECIALTY #02921 $2,958,925 68
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW WEST $1,659,911 175
UNITED HOSPITAL $1,657,168 242
MAYO CLINIC ROCHESTER $1,275,346 93
HEALTHEAST ST JOHNS & MIDWAY $1,071,439 286
MERCY HOSPITAL $800,492 58
MAYO CLINIC HOSPITAL-ROCHESTER $770,237 34
HEALTHPARTNERS MAIL ORDER PHARMACY $736,383 525
MINNESOTA ONCOLOGY HEMATOLOGY, PA $633,004 55
HEALTHEAST WOODWINDS HOSPITAL $609,700 160
ABBOTT NORTHWESTERN HOSPITAL $597,840 123
FAIRVIEW PHARMACY SERVICES LLC-HH $594,346 5 or under
PARK NICOLLET CLINIC $573,868 383
CVS PHARMACY # $552,701 1,321
HEALTHEAST ST JOSEPHS $505,879 80
PARK NICOLLET METHODIST HOSPITAL-ACUTE $469,638 85
FAIRVIEW SOUTHDALE HOSPITAL $443,343 78
CHILDRENS HEALTH CARE-ST PAUL $439,984 186
HEALTHPARTNERS SAME DAY SURG CENTER $422,767 261
SUMMIT ORTHOPEDICS,LTD $366,680 264
LAKEVIEW HOSPITAL $310,539 90
All Packages/All Sites YTD Qtrly
Prior Year by Dollars Paid
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 50 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service CategoriesProvider Claims ClaimantsTWIN CITIES ORTHOPEDICS,PA $309,085 196
MINNESOTA GASTROENTEROLOGY PA $305,177 221
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 51 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Top 25 Medical Providers - All Service Categories
Provider Claimants ClaimsHEALTHPARTNERS MEDICAL GROUP 3,613 $5,024,668
ST PAUL RADIOLOGY PA 1,304 $285,566
CVS PHARMACY # 1,281 $569,310
REGIONS HOSPITAL-RAD/ACUTE/SLEEP 854 $3,443,124
HEALTHPARTNERS WORKSITE HEALTH 592 $20,001
WALGREENS 590 $283,129
CVS PHARMACY 561 $192,121
FULCRUM HEALTH,INC 544 $83,171
HEALTHPARTNERS MAIL ORDER PHARMACY 502 $758,697
NOT APPLICABLE 458 $15,425
PARK NICOLLET CLINIC 384 $614,390
CUB PHARMACY 331 $220,876
MINUTECLINIC DIAGNOSTIC OF MN PA 316 $18,972
EMERGENCY PHYSICIANS,PA 295 $201,873
HOSPITAL PATHOLOGY ASSOCIATES 292 $50,321
REGIONS HOSPITAL-PRO FEE 291 $170,160
HEALTHPARTNERS MENTAL HEALTH 287 $257,960
HEALTHEAST ST JOHNS & MIDWAY 285 $1,058,010
SUMMIT ORTHOPEDICS,LTD 280 $421,249
DERMATOLOGY CONSULTANTS,PA 279 $122,349
HEALTHPARTNERS SAME DAY SURG CENTER 267 $469,661
HEALTHPARTNERS ST. PAUL PHARMACY 266 $87,642
VIRTUWELL 256 $15,215
All Packages/All Sites YTD Qtrly
Current Year by Claimant Count
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 52 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Top 25 Medical Providers - All Service CategoriesProvider Claimants ClaimsST PAUL EYE CLINIC,PA 254 $82,272
MINNESOTA GASTROENTEROLOGY PA 246 $343,259
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 53 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service Categories
Provider Claimants ClaimsHEALTHPARTNERS MEDICAL GROUP 3,695 $4,809,334
ST PAUL RADIOLOGY PA 1,344 $275,485
CVS PHARMACY # 1,321 $552,701
REGIONS HOSPITAL-RAD/ACUTE/SLEEP 962 $3,418,292
HEALTHPARTNERS WORKSITE HEALTH 681 $23,155
WALGREENS 628 $302,999
CVS PHARMACY 532 $203,898
HEALTHPARTNERS MAIL ORDER PHARMACY 525 $736,383
FULCRUM HEALTH,INC 505 $79,446
PARK NICOLLET CLINIC 383 $573,868
REGIONS HOSPITAL-PRO FEE 339 $176,086
CUB PHARMACY 337 $284,458
NOT APPLICABLE 334 $12,189
EMERGENCY PHYSICIANS,PA 294 $209,920
HOSPITAL PATHOLOGY ASSOCIATES 288 $62,512
HEALTHEAST ST JOHNS & MIDWAY 286 $1,071,439
HEALTHPARTNERS MENTAL HEALTH 282 $257,917
ST PAUL EYE CLINIC,PA 272 $80,188
SUMMIT ORTHOPEDICS,LTD 264 $366,680
HEALTHPARTNERS SAME DAY SURG CENTER 261 $422,767
DERMATOLOGY CONSULTANTS,PA 258 $104,489
VIRTUWELL 258 $16,058
HEALTHPARTNERS MEDICAL GROUP-NW ALLIANCE 247 $186,703
All Packages/All Sites YTD Qtrly
Prior Year by Claimant Count
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 54 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service CategoriesProvider Claimants ClaimsUNITED HOSPITAL 242 $1,657,168
HEALTHPARTNERS WOODBURY PHARMACY 235 $68,663
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 55 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Effect of Catastrophic Claims on PMPM
Amount Aggregate Variance PMPM Trend
Total Claims $51,567,481
Total Claims: Per Member Per Month $558.38 $468.99 19.06% -1.10%
Catastrophic Claims Excess Amount $14,709,696 (for members with $25,000 +, the amount over $25,000
Catastrophic Excess Amount: % of Total Claims 28.53% 31.18%
(catastrophic claims as a percentage of total claims)
Net Claims $36,857,785
(total claims less catastrophic excess)
Net Claims: Per Member Per Month $399.10 $322.77 23.65% 1.09%
Note: Catastrophic Dollars do not include IBNR Claims include IBNR
All Packages/All Sites YTD Qtrly
Current Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00:00 A © Copyright 2018 HealthPartners
400_Ex_Effect_Catastrophic_ClaimsReport Id: 43735
Page 56 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Effect of Catastrophic Claims on PMPM
Amount Aggregate Variance
Total Claims $51,448,336
Total Claims: Per Member Per Month $564.57 $458.40 23.16%
Catastrophic Claims Excess Amount $15,470,710 (for members with $25,000 +, the amount over $25,000
Catastrophic Excess Amount: % of Total Claims 30.07% 30.66%
(catastrophic claims as a percentage of total claims)
Net Claims $35,977,626
(total claims less catastrophic excess)
Net Claims: Per Member Per Month $394.80 $317.84 24.21%
Note: Catastrophic Dollars do not include IBNR Claims include IBNR
All Packages/All Sites YTD Qtrly
Prior Year
Run Date: 02/12/2018Report Period: 2/1/2018 12:00:00 A © Copyright 2018 HealthPartners
400_Ex_Effect_Catastrophic_ClaimsReport Id: 43735
Page 57 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical PMPM Before and After Removing Claims in Excess of Catastrophic Threshold
All Packages/All Sites YTD Qtrly
C CCurrent Year Current Aggregate P Prior Year Prior AggregateP
Report Period: 2/1/2018 12:00:00 ARun Date: 02/12/2018
© Copyright 2018 HealthPartners Report Id: 43735400_Ex_Effect_Catastrophic_Claims
Page 58 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Distribution of Claimants and Dollars
Dollar RangeNumber ofClaimants Claims
Cumulative %of Claimants
Cumulative %of Claims
Cumulative %of Claimants
Cumulative %of Claims
1 - 250 942 $104,332 12.40% 0.22% 20.30% 0.35%
250 - 500 789 $292,384 22.79% 0.82% 33.12% 1.26%
500 - 1000 1,187 $869,454 38.43% 2.63% 50.09% 3.60%
1000 - 2500 1,731 $2,827,736 61.22% 8.51% 69.59% 9.61%
2500 - 5000 1,156 $4,095,470 76.44% 17.01% 81.51% 17.67%
5000 - 10000 743 $5,256,418 86.23% 27.94% 89.20% 27.99%
10000 - 15000 342 $4,198,903 90.73% 36.66% 92.63% 36.05%
15000 - 25000 302 $5,727,016 94.71% 48.56% 95.81% 47.77%
25000 - 35000 138 $4,065,046 96.52% 57.00% 97.23% 55.75%
35000 - 50000 89 $3,746,822 97.70% 64.79% 98.27% 63.98%
50000 - 75000 81 $4,776,493 98.76% 74.71% 99.08% 73.28%
75000 - 100000 51 $4,432,835 99.43% 83.92% 99.45% 79.34%
100000 - 125000 18 $1,978,287 99.67% 88.03% 99.63% 83.19%
125000+ 25 $5,760,214 100.00% 100.00% 100.00% 100.00%
7,594 $48,131,408
All Packages/All Sites YTD Qtrly
AggregateCurrent Year Actual
Note: Claims do not include IBNR
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
410_Ex_Distribution_of_ClaimantsReport Id: 43735
Page 59 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Distribution of Claimants and Dollars
Dollar RangeNumber ofClaimants Claims
Cumulative %of Claimants
Cumulative %of Claims
Cumulative %of Claimants
Cumulative %of Claims
1 - 250 960 $107,990 12.75% 0.22% 19.65% 0.35%
250 - 500 753 $279,246 22.74% 0.81% 32.49% 1.27%
500 - 1000 1,161 $844,188 38.16% 2.56% 49.41% 3.65%
1000 - 2500 1,741 $2,861,298 61.27% 8.52% 69.39% 9.89%
2500 - 5000 1,153 $4,081,683 76.58% 17.03% 81.48% 18.15%
5000 - 10000 785 $5,505,076 87.00% 28.49% 89.31% 28.80%
10000 - 15000 317 $3,910,106 91.21% 36.64% 92.82% 37.12%
15000 - 25000 280 $5,402,052 94.93% 47.89% 96.00% 48.95%
25000 - 35000 137 $4,032,976 96.75% 56.29% 97.39% 56.91%
35000 - 50000 96 $3,944,164 98.02% 64.50% 98.36% 64.72%
50000 - 75000 66 $3,840,573 98.90% 72.50% 99.13% 73.66%
75000 - 100000 34 $2,900,994 99.35% 78.54% 99.47% 79.42%
100000 - 125000 17 $1,956,578 99.58% 82.62% 99.65% 83.19%
125000+ 32 $8,345,427 100.00% 100.00% 100.00% 100.00%
7,532 $48,012,348
All Packages/All Sites YTD Qtrly
AggregatePrior Year Actual
Note: Claims do not include IBNR
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
410_Ex_Distribution_of_ClaimantsReport Id: 43735
Page 60 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Distribution of Member Liability
Member LiabilityDollar Range
Number ofClaimants
MemberLiability Claims
Cumulative %of Claimants
Cumulative % ofMember LIability
Cumulative %of Claims
1 - 250 3,904 $381,441 $4,097,581 51.41% 11.41% 8.51%
250 - 500 1,467 $528,145 $5,871,712 70.73% 27.21% 20.71%
500 - 1000 1,204 $846,541 $9,652,923 86.58% 52.54% 40.77%
1000 - 2500 966 $1,405,860 $25,853,715 99.30% 94.59% 94.48%
2500 - 5000 53 $180,724 $2,655,477 100.00% 100.00% 100.00%
5000 - 10000 0 $0 $0 100.00% 100.00% 100.00%
10000+ 0 $0 $0 100.00% 100.00% 100.00%
Total 7,594 $3,342,712 $48,131,408
All Packages/All Sites YTD Qtrly
Current Year Actual
Note: Claims do not include IBNR
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
415_Ex_Distribution_of_Member_LiReport Id: 43735
Page 61 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Distribution of Member Liability
Member LiabilityDollar Range
Number ofClaimants
MemberLiability Claims
Cumulative %of Claimants
Cumulative % ofMember Liability
Cumulative %of Claims
1 - 250 3,935 $381,175 $4,196,481 52.24% 11.96% 8.74%
250 - 500 1,507 $536,219 $6,257,419 72.25% 28.78% 21.77%
500 - 1000 1,144 $802,424 $9,426,570 87.44% 53.96% 41.41%
1000 - 2500 900 $1,312,105 $25,942,394 99.39% 95.12% 95.44%
2500 - 5000 46 $155,510 $2,189,485 100.00% 100.00% 100.00%
5000 - 10000 0 $0 $0 100.00% 100.00% 100.00%
10000+ 0 $0 $0 100.00% 100.00% 100.00%
Total 7,532 $3,187,434 $48,012,348
All Packages/All Sites YTD Qtrly
Prior Year Actual
Note: Claims do not include IBNR
Run Date: 02/12/2018Report Period: 2/1/2018 12:00: © Copyright 2018 HealthPartners
415_Ex_Distribution_of_Member_LiReport Id: 43735
Page 62 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsMalignant Neoplasm Of Frontal Lobe $383,788Infection And Inflammatory Reaction Due To Other Cardiac And Vascular Devices,Implants And Grafts, Initial Encounter $383,017
Fabry (-anderson) Disease $340,422
Embolism And Thrombosis Of Arteries Of The Lower Extremities $335,632
Encounter For Antineoplastic Radiation Therapy $309,668
Tetralogy Of Fallot $306,978
Malignant Neoplasm Of Ascending Colon $291,187
Secondary Malignant Neoplasm Of Bone $288,240
Multiple Myeloma Not Having Achieved Remission $284,935
Spondylolisthesis, Lumbar Region $264,296
Nonrheumatic Tricuspid (valve) Insufficiency $235,992
End Stage Renal Disease $224,781
Malignant Neoplasm Of Lower-inner Quadrant Of Left Female Breast $206,408
Infection Following A Procedure, Initial Encounter $192,155
Cystic Fibrosis, Unspecified $185,240
Hypertensive Heart Disease With Heart Failure $183,092
End Stage Renal Disease $182,685
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 63 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsSpinal Stenosis, Cervical Region $172,627
Malignant Melanoma Of Right Lower Limb, Including Hip $158,854
Ulcerative Colitis, Unspecified, Without Complications $155,234
Other Specified Disorders Of Breast $147,425
Encounter For Aftercare Following Heart Transplant $137,385
Encounter For Aftercare Following Liver Transplant $131,017
Malignant Neoplasm Of Unspecified Site Of Left Female Breast $130,314
Sepsis, Unspecified Organism $128,841
Obstructive Sleep Apnea (adult) (pediatric) $121,482
Malignant Neoplasm Of Central Portion Of Right Female Breast $119,962
Ventricular Premature Depolarization $119,854
Sensitive Diagnosis $119,194
Other Chronic Pain $115,534
Pathological Fracture, Other Site, Initial Encounter For Fracture $112,919
Malignant Neoplasm Of Temporal Lobe $112,827Peptic Ulcer, Site Unspecified, Unspecified As Acute Or Chronic, Without Hemorrhage OrPerforation $112,406
Abnormal Uterine And Vaginal Bleeding, Unspecified $111,951
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 64 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsCrohn's Disease Of Both Small And Large Intestine With Fistula $111,229
Carpal Tunnel Syndrome, Right Upper Limb $109,337
Other Spondylosis With Radiculopathy, Lumbar Region $103,957St Elevation (stemi) Myocardial Infarction Involving Left Anterior Descending CoronaryArtery $103,270
End Stage Renal Disease $101,454
Undifferentiated Schizophrenia $100,803
Multiple Sclerosis $100,787
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $100,711
Myelodysplastic Syndrome, Unspecified $100,612
Malignant Carcinoid Tumor Of The Bronchus And Lung $99,945
Other Internal Derangements Of Left Knee $99,671
Other Postprocedural Cardiac Functional Disturbances Following Other Surgery $99,661
Multiple Sclerosis $99,450
Congenital Stenosis Of Aortic Valve $99,209
Malignant Neoplasm Of Upper Lobe, Right Bronchus Or Lung $99,185
Flatback Syndrome, Lumbar Region $99,130
St Elevation (stemi) Myocardial Infarction Involving Left Circumflex Coronary Artery $98,539
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 65 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsMalignant Neoplasm Of Overlapping Sites Of Bladder $98,428
Urgency Of Urination $97,685
Sensitive Diagnosis $94,088
Benign Neoplasm Of Ascending Colon $93,348
Nocturia $93,269
Sensitive Diagnosis $92,597
Atrioventricular Block, Complete $92,309
Postmenopausal Bleeding $90,423
Benign Neoplasm Of Pituitary Gland $90,215
Juvenile Arthritis, Unspecified, Unspecified Site $89,759
Sepsis, Unspecified Organism $89,464
Secondary Malignant Neoplasm Of Retroperitoneum And Peritoneum $88,949
Hypermetropia, Bilateral $88,069
Malignant Neoplasm Of Unspecified Part Of Unspecified Bronchus Or Lung $87,792
Craniosynostosis $87,555
Low Back Pain $87,409
Sensitive Diagnosis $87,251
Multiple Sclerosis $86,795
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 66 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnilateral Primary Osteoarthritis, Right Hip $86,648
Malignant Neoplasm Of Lower-outer Quadrant Of Left Female Breast $86,507
Intrahepatic Bile Duct Carcinoma $86,441
Spinal Stenosis, Lumbar Region With Neurogenic Claudication $85,704
Sensitive Diagnosis $85,008
Spinal Stenosis, Lumbar Region With Neurogenic Claudication $84,611
Sensitive Diagnosis $84,281
Sensitive Diagnosis $83,855
Other Complications Of Other Bariatric Procedure $81,988
Guillain-barre Syndrome $81,965
Spinal Stenosis, Lumbar Region Without Neurogenic Claudication $80,838
Spinal Stenosis, Lumbar Region $79,022
Sepsis, Unspecified Organism $78,092Infection And Inflammatory Reaction Due To Internal Right Hip Prosthesis, InitialEncounter $77,342
Nontraumatic Intracerebral Hemorrhage, Intraventricular $77,337
Trigeminal Neuralgia $77,186
Type 1 Diabetes Mellitus Without Complications $76,861
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 67 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsFracture Of Nasal Bones, Initial Encounter For Closed Fracture $76,758
End Stage Renal Disease $76,544
Other Specified Disorders Of Nose And Nasal Sinuses $76,234
Multiple Sclerosis $76,126
Morbid (severe) Obesity Due To Excess Calories $76,077
Cerebral Infarction, Unspecified $76,058
Precocious Puberty $75,723
Other Tear Of Medial Meniscus, Current Injury, Right Knee, Initial Encounter $75,434
Sensitive Diagnosis $73,338
Rheumatoid Lung Disease With Rheumatoid Arthritis Of Multiple Sites $73,063
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $70,643
Chronic Obstructive Pulmonary Disease With (acute) Exacerbation $70,587
Other Mechanical Complication Of Internal Right Hip Prosthesis, Initial Encounter $70,552
Unilateral Primary Osteoarthritis, Right Knee $70,526
Unspecified Atrial Flutter $70,462
Unilateral Primary Osteoarthritis, Right Hip $68,869
Sensitive Diagnosis $67,760
Cholangitis $67,506
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 68 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsMorbid (severe) Obesity Due To Excess Calories $67,368
Saddle Embolus Of Pulmonary Artery With Acute Cor Pulmonale $67,181
Endometriosis Of Uterus $66,909
End Stage Renal Disease $66,502
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $66,219
Other Mechanical Complication Of Internal Left Hip Prosthesis, Initial Encounter $66,019
Multiple Sclerosis $65,758
Epilepsy, Unspecified, Not Intractable, Without Status Epilepticus $65,738
Inflammatory Polyarthropathy $65,497Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Left Middle CerebralArtery $65,471
Gastro-esophageal Reflux Disease With Esophagitis $64,165
Anaphylactic Shock, Unspecified, Initial Encounter $64,148
Tubulo-interstitial Nephritis, Not Specified As Acute Or Chronic $63,332
Malignant Neoplasm Of Thyroid Gland $63,215
Unilateral Primary Osteoarthritis, Left Knee $62,722
Sensitive Diagnosis $62,468
Dissection Of Carotid Artery $62,427
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 69 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsMorbid (severe) Obesity Due To Excess Calories $61,817
Crohn's Disease Of Small Intestine Without Complications $60,479
Contracture, Unspecified Ankle $60,468
Other Encephalopathy $60,151
Other Sprain Of Left Shoulder Joint, Initial Encounter $59,758
Sensitive Diagnosis $58,923
Encounter For Antineoplastic Radiation Therapy $58,771
Type 1 Diabetes Mellitus With Hyperglycemia $58,712
Malignant Neoplasm Of Thyroid Gland $58,542
Paroxysmal Atrial Fibrillation $58,472
Infection Following A Procedure, Initial Encounter $58,333
Sensitive Diagnosis $58,102
Malignant Neoplasm Of Upper Lobe, Left Bronchus Or Lung $58,048
Other Psoriasis $57,700
Malignant Neoplasm Of Overlapping Sites Of Right Female Breast $57,502
Infection Following A Procedure, Initial Encounter $57,407
Influenza Due To Other Identified Influenza Virus With Other Respiratory Manifestations $57,282
Other Specified Disorders Of Nose And Nasal Sinuses $57,232
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 70 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsMalignant Neoplasm Of Upper Lobe, Right Bronchus Or Lung $57,139
Other Chest Pain $56,520
Cervical Disc Disorder At C5-c6 Level With Radiculopathy $55,949
Mammary Duct Ectasia Of Right Breast $55,807
Non-st Elevation (nstemi) Myocardial Infarction $55,674
Right Lower Quadrant Pain $55,486
Other Specified Joint Disorders, Left Hip $55,102
Infection Following A Procedure, Initial Encounter $55,093
Type 1 Diabetes Mellitus Without Complications $54,943
Rheumatoid Arthritis, Unspecified $54,808
Unilateral Primary Osteoarthritis, Right Knee $54,609
Calculus Of Ureter $53,849
Sensitive Diagnosis $53,808Rheumatoid Arthritis With Rheumatoid Factor Of Multiple Sites Without Organ Or SystemsInvolvement $53,710
Other Long Term (current) Drug Therapy $53,689
Other Hyperfunction Of Pituitary Gland $53,627
Mild Cognitive Impairment, So Stated $53,582
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 71 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther Specified Diseases Of Spinal Cord $53,369
Toxic Encephalopathy $53,247
Sensitive Diagnosis $53,101
Obstruction Of Bile Duct $52,579
St Elevation (stemi) Myocardial Infarction Of Unspecified Site $52,526
Sepsis, Unspecified Organism $51,753
Crohn's Disease Of Large Intestine With Unspecified Complications $51,642
Morbid (severe) Obesity Due To Excess Calories $51,535
Persistent Atrial Fibrillation $51,467
Dysphagia, Unspecified $50,883
Sensitive Diagnosis $50,882
Hypospadias, Perineal $50,789
Intrahepatic Bile Duct Carcinoma $50,754
Encounter For Other Specified Surgical Aftercare $50,516
Other Chronic Pain $50,461
Other Specified Cardiac Arrhythmias $50,443
Sensitive Diagnosis $50,366
Unilateral Primary Osteoarthritis, Right Knee $50,350
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 72 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsPersistent Atrial Fibrillation $50,291
Chronic Sinusitis, Unspecified $49,889
Pain In Right Foot $49,674
Peripheral Vascular Disease, Unspecified $49,664
Sensitive Diagnosis $49,412
Myopia, Bilateral $49,291
Scar Conditions And Fibrosis Of Skin $49,042
Sensitive Diagnosis $49,021
Umbilical Hernia Without Obstruction Or Gangrene $48,908
Malignant Neoplasm Of Pancreas, Unspecified $48,804
Conversion Disorder With Seizures Or Convulsions $48,304
Infection Following A Procedure, Initial Encounter $48,041
Sensitive Diagnosis $47,875
Sensitive Diagnosis $47,843
Brachial Plexus Disorders $47,622
Calculus Of Gallbladder Without Cholecystitis Without Obstruction $47,402
Food Protein-induced Enterocolitis Syndrome $47,259
Ventricular Premature Depolarization $47,035
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 73 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsFistula Of Vagina To Large Intestine $46,521
Systemic Lupus Erythematosus, Unspecified $46,450
Sensitive Diagnosis $46,375
Spinal Stenosis, Lumbar Region Without Neurogenic Claudication $46,308Encounter For Adjustment And Management Of Automatic Implantable CardiacDefibrillator $46,129
Non-hodgkin Lymphoma, Unspecified, Unspecified Site $46,037
Multiple Sclerosis $45,898
Submucous Leiomyoma Of Uterus $45,815
Sensitive Diagnosis $45,654
Prolapse Of Vaginal Vault After Hysterectomy $45,426
Sensitive Diagnosis $45,304
Cervical Disc Disorder At C5-c6 Level With Radiculopathy $45,134
Non-st Elevation (nstemi) Myocardial Infarction $44,730
Unilateral Primary Osteoarthritis, Left Knee $44,693Atherosclerotic Heart Disease Of Native Coronary Artery With Unspecified AnginaPectoris $44,195
Sensitive Diagnosis $43,788
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 74 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnilateral Osteoarthritis Resulting From Hip Dysplasia, Left Hip $43,367
Morbid (severe) Obesity Due To Excess Calories $43,093
Occlusion And Stenosis Of Left Carotid Artery $42,754
Estrogen Receptor Positive Status [er+] $42,536
Diverticulitis Of Large Intestine Without Perforation Or Abscess Without Bleeding $42,478Rheumatoid Arthritis With Rheumatoid Factor Of Multiple Sites Without Organ Or SystemsInvolvement $42,248
Spinal Stenosis, Cervical Region $42,238
Diverticulitis Of Large Intestine Without Perforation Or Abscess Without Bleeding $42,155
Non-st Elevation (nstemi) Myocardial Infarction $42,031
Sensitive Diagnosis $41,694
Cervical Disc Disorder At C5-c6 Level With Radiculopathy $41,690
Bilateral Primary Osteoarthritis Of Hip $41,619
Obstructive Sleep Apnea (adult) (pediatric) $41,526
Other Specified Disorders Of Kidney And Ureter $41,441
Other Specified Retinal Disorders $40,974
Malignant Neoplasm Of Prostate $40,570
Sensitive Diagnosis $40,558
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 75 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther And Unspecified Ventral Hernia With Obstruction, Without Gangrene $40,518
Chronic Cholecystitis $40,429
Pre-existing Type 1 Diabetes Mellitus, In Childbirth $40,141
Retinal Detachment With Multiple Breaks, Left Eye $40,141
Other Hypoglycemia $40,087
Sensitive Diagnosis $39,940
Hallux Valgus (acquired), Left Foot $39,795
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $39,730
Malignant Neoplasm Of Bladder, Unspecified $39,688
Encounter For Screening For Malignant Neoplasm Of Colon $39,634
Sensitive Diagnosis $39,528
Sensitive Diagnosis $39,288
Sensitive Diagnosis $39,131
Influenza Due To Other Identified Influenza Virus With Other Respiratory Manifestations $39,067
Other Instability, Left Ankle $39,020
Bilateral Primary Osteoarthritis Of Knee $38,740
Primary Osteoarthritis, Right Elbow $38,659
Precordial Pain $38,538
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 76 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $38,508
Other Effects Of High Altitude, Initial Encounter $37,961
Atrial Premature Depolarization $37,849
Sensitive Diagnosis $37,846
Morbid (severe) Obesity Due To Excess Calories $37,681
Acute Cystitis Without Hematuria $37,546
Allergic Rhinitis Due To Pollen $37,397
Ulcerative Colitis, Unspecified, Without Complications $37,375
Sensitive Diagnosis $37,030
Gastrointestinal Hemorrhage, Unspecified $36,502
Hypocalcemia $36,294
Mechanical Loosening Of Internal Left Knee Prosthetic Joint, Initial Encounter $36,110
Supraventricular Tachycardia $36,104
Unilateral Primary Osteoarthritis, Right Knee $35,971
Encounter For Aftercare Following Kidney Transplant $35,888
Osteonecrosis Due To Previous Trauma, Right Femur $35,458
Sensitive Diagnosis $35,365
Unilateral Primary Osteoarthritis, Right Hip $35,365
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 77 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsStenosis Of Pulmonary Artery $35,342
Unilateral Primary Osteoarthritis, Right Knee $35,331
Sensitive Diagnosis $35,312
Malignant Neoplasm Of Sigmoid Colon $34,975
Disproportion Of Reconstructed Breast $34,772
Sensitive Diagnosis $34,758
Unilateral Primary Osteoarthritis, Left Knee $34,611
Acute On Chronic Systolic (congestive) Heart Failure $34,571Displaced Fracture (avulsion) Of Medial Epicondyle Of Right Humerus, Initial EncounterFor Closed Fracture $34,512
Strain Of Muscle(s) And Tendon(s) Of The Rotator Cuff Of Right Shoulder, InitialEncounter $34,483
Noninfective Gastroenteritis And Colitis, Unspecified $34,418
Sensitive Diagnosis $34,400
Maxillary Hypoplasia $34,333
Urticaria, Unspecified $34,219
Dental Caries, Unspecified $34,187
Type 2 Diabetes Mellitus Without Complications $34,140
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 78 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsAcute Appendicitis With Generalized Peritonitis $34,035
Uterovaginal Prolapse, Unspecified $33,854
Sensitive Diagnosis $33,743
Other Long Term (current) Drug Therapy $33,677
Sensitive Diagnosis $33,525
Sensitive Diagnosis $33,489
Excessive And Frequent Menstruation With Regular Cycle $33,417
Ulcer Of Intestine $33,409
Malignant Neoplasm Of Unspecified Ovary $33,338
Acute Appendicitis With Generalized Peritonitis $33,138
Sensitive Diagnosis $32,863
Atrioventricular Block, Complete $32,721
Sensitive Diagnosis $32,694
Ulcerative (chronic) Pancolitis Without Complications $32,637
Recurrent Dislocation Of Patella, Right Knee $32,453
Sensitive Diagnosis $32,324
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $32,272
Sensitive Diagnosis $32,229
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 79 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnilateral Primary Osteoarthritis, Left Knee $32,122
Sensitive Diagnosis $32,021
Unilateral Primary Osteoarthritis, Right Knee $31,929
Sensitive Diagnosis $31,924
Sprain Of Anterior Cruciate Ligament Of Left Knee, Initial Encounter $31,823
Arthropathic Psoriasis, Unspecified $31,820
Unilateral Primary Osteoarthritis, Left Knee $31,724
Sensitive Diagnosis $31,648
Solitary Pulmonary Nodule $31,488
Acute And Subacute Hepatic Failure Without Coma $31,365
Unilateral Primary Osteoarthritis, Right Knee $31,241
Bilateral Primary Osteoarthritis Of Knee $31,204
Incomplete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $31,181
Chronic Pansinusitis $31,063
Unspecified Acute Appendicitis $31,032
Unilateral Primary Osteoarthritis, Left Knee $30,869
Ankylosing Spondylitis Of Multiple Sites In Spine $30,831
Unilateral Primary Osteoarthritis, Left Hip $30,675
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 80 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsCholangitis $30,601
Hydronephrosis With Renal And Ureteral Calculous Obstruction $30,492
Diaphragmatic Hernia Without Obstruction Or Gangrene $30,418
Sensitive Diagnosis $30,404
Dysplasia Of Vagina, Unspecified $30,150
Sensitive Diagnosis $30,091
End Stage Renal Disease $30,009
Instability Of Internal Right Knee Prosthesis, Initial Encounter $29,830
Precocious Puberty $29,795
Unilateral Primary Osteoarthritis, Right Hip $29,637
Incisional Hernia With Obstruction, Without Gangrene $29,578
Acute Appendicitis With Generalized Peritonitis $29,563
Tremor, Unspecified $29,258
Unilateral Primary Osteoarthritis, Right Hip $29,216
Sensitive Diagnosis $29,215
Other Specified Disorders Of Nose And Nasal Sinuses $29,188
Supraventricular Tachycardia $29,027
Stress Incontinence (female) (male) $29,001
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 81 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther Chest Pain $28,944
Unilateral Primary Osteoarthritis, Left Knee $28,925
Type 1 Diabetes Mellitus With Hyperglycemia $28,915
Peritoneal Adhesions (postprocedural) (postinfection) $28,907
Unspecified Acute Appendicitis $28,850
Other Specified Noninflammatory Disorders Of Uterus $28,850Hypertensive Heart And Chronic Kidney Disease With Heart Failure And Stage 1 ThroughStage 4 Chronic Kidney Disease, Or Unspecified Chronic Kidney Disease $28,753
Sensitive Diagnosis $28,733
Unilateral Primary Osteoarthritis, Right Knee $28,675
Sensitive Diagnosis $28,637
Other Chronic Pain $28,604Exudative Age-related Macular Degeneration, Left Eye, With Active ChoroidalNeovascularization $28,544
Hallux Valgus (acquired), Right Foot $28,475
Sensitive Diagnosis $28,465
Torsion Of Right Ovary And Ovarian Pedicle $28,431
Snoring $28,216
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 82 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsSudden Idiopathic Hearing Loss, Right Ear $28,142
Sensitive Diagnosis $28,112
Type 2 Diabetes Mellitus With Hyperglycemia $28,091Type 2 Diabetes Mellitus With Proliferative Diabetic Retinopathy With Macular Edema,Left Eye $28,083
Sensitive Diagnosis $27,949
Encounter For Screening For Malignant Neoplasm Of Colon $27,885
Sensitive Diagnosis $27,768
Urticaria, Unspecified $27,742
Sensitive Diagnosis $27,665
Other Bursitis Of Knee, Left Knee $27,648
Unspecified Abdominal Pain $27,605
Complete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $27,528
Unilateral Primary Osteoarthritis, Left Knee $27,486
Calculus Of Kidney With Calculus Of Ureter $27,386
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $27,376
Malignant Neoplasm Of Prostate $27,279
Encounter For Preprocedural Cardiovascular Examination $27,210
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 83 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsMorbid (severe) Obesity Due To Excess Calories $27,178
Unilateral Primary Osteoarthritis, Left Hip $27,076
Sensitive Diagnosis $27,049
Cutaneous Abscess Of Left Axilla $27,039
Personal History Of Malignant Neoplasm Of Other Female Genital Organs $27,033
Muscle Weakness (generalized) $26,977
Pain In Thoracic Spine $26,689
Excessive And Frequent Menstruation With Regular Cycle $26,681
Unilateral Primary Osteoarthritis, Right Knee $26,640
Cough $26,577
Intestinal Adhesions [bands] With Obstruction (postinfection) $26,549
Unilateral Primary Osteoarthritis, Right Knee $26,391
Unilateral Post-traumatic Osteoarthritis, Left Knee $26,374
Unspecified Lack Of Coordination $26,280
Unspecified Open Wound, Right Thigh, Initial Encounter $26,275
Other Long Term (current) Drug Therapy $26,271
Morbid (severe) Obesity Due To Excess Calories $26,125
Excessive And Frequent Menstruation With Regular Cycle $25,996
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 84 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsUmbilical Hernia Without Obstruction Or Gangrene $25,950
Dehydration $25,860Other Specified Complication Of Internal Orthopedic Prosthetic Devices, Implants AndGrafts, Initial Encounter $25,783
Type 1 Diabetes Mellitus With Hyperglycemia $25,758
Sensitive Diagnosis $25,755
Gestational Diabetes Mellitus In Childbirth, Controlled By Oral Hypoglycemic Drugs $25,755
Sensitive Diagnosis $25,725
Occlusion And Stenosis Of Right Carotid Artery $25,683
Morbid (severe) Obesity Due To Excess Calories $25,566
Sensitive Diagnosis $25,495
Type 1 Diabetes Mellitus With Ketoacidosis Without Coma $25,453
Morbid (severe) Obesity Due To Excess Calories $25,421Strain Of Other Muscles, Fascia And Tendons At Shoulder And Upper Arm Level, RightArm, Initial Encounter $25,407
Hypertrophy Of Breast $25,366
Cerebral Infarction, Unspecified $25,328
Sensitive Diagnosis $25,290
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 85 of 109
Ramsey County [12900]
Paid through 01/31/2018Service Dates of 01/01/2017 through 12/31/2017
Medical Catastrophic Cases
Principal Diagnosis ClaimsIntraductal Carcinoma In Situ Of Right Breast $25,289
Intramural Leiomyoma Of Uterus $25,283Other Intraoperative And Postprocedural Complications And Disorders Of TheMusculoskeletal System $25,113
Headache $25,060
Total $24,759,696
Total Above $25,000 $14,709,696
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 86 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsDilated Cardiomyopathy $859,471
Fabry (-anderson) Disease $556,880
Secondary Malignant Neoplasm Of Bone $488,978
Laceration Of Liver, Unspecified Degree, Initial Encounter $448,730
Tetralogy Of Fallot $393,461
Malignant Melanoma Of Skin, Unspecified $335,966
Acute Respiratory Failure With Hypoxia $326,481
Sepsis Due To Methicillin Susceptible Staphylococcus Aureus $324,203
End Stage Renal Disease $315,603
Secondary Malignant Neoplasm Of Other Parts Of Nervous System $287,241
Encounter For Antineoplastic Immunotherapy $286,700
Malignant Neoplasm Of Ascending Colon $286,614
Ulcerative Colitis, Unspecified, Without Complications $266,554
Malignant Neoplasm Of Prostate $203,540Pathological Fracture In Neoplastic Disease, Other Specified Site, Initial Encounter ForFracture $200,597
Postsurgical Lordosis $197,035
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 87 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSt Elevation (stemi) Myocardial Infarction Involving Left Anterior Descending CoronaryArtery $194,777
Benign Neoplasm Of Peripheral Nerves And Autonomic Nervous System Of Abdomen $190,962
Malignant Neoplasm Of Brain, Unspecified $185,472Encounter For Adjustment And Management Of Automatic Implantable CardiacDefibrillator $181,971
Stenosis Of Other Cardiac Prosthetic Devices, Implants And Grafts, Initial Encounter $179,583
Sensitive Diagnosis $171,247
Malignant Neoplasm Of Upper-outer Quadrant Of Right Female Breast $167,742
Unspecified Juvenile Rheumatoid Arthritis Of Unspecified Site $163,761
Malignant Neoplasm Of Pancreas, Unspecified $161,727
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $155,088
Primary Osteoarthritis, Left Shoulder $151,697
Sensitive Diagnosis $140,930
Malignant Neoplasm Of Unspecified Part Of Right Bronchus Or Lung $136,666
Idiopathic Acute Pancreatitis $129,773
Spinal Stenosis, Cervical Region $129,425
Spinal Stenosis, Cervical Region $126,554
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 88 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsNonrheumatic Aortic (valve) Stenosis With Insufficiency $124,852
Obstructive Sleep Apnea (adult) (pediatric) $122,886
Malignant Neoplasm Of Central Portion Of Right Female Breast $121,503
Other Secondary Pulmonary Hypertension $121,232
Malignant Melanoma Of Right Lower Limb, Including Hip $120,915
Spondylolisthesis, Lumbar Region $120,492
Malignant Neoplasm Of Lower-outer Quadrant Of Left Female Breast $120,184
End Stage Renal Disease $116,147
Sepsis, Unspecified Organism $115,629
End Stage Renal Disease $115,366
Malignant Neoplasm Of Upper-outer Quadrant Of Left Female Breast $115,155
Myelodysplastic Syndrome, Unspecified $111,632
Chronic Myeloid Leukemia, Bcr/abl-positive, Not Having Achieved Remission $109,347
Neuromuscular Dysfunction Of Bladder, Unspecified $109,140
Sensitive Diagnosis $105,759
Benign Neoplasm Of Cerebral Meninges $103,981
Malignant Neoplasm Of Overlapping Sites Of Left Female Breast $102,356
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 89 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsMultiple Sclerosis $99,482
Urethral Stricture, Unspecified $96,376
Malignant Neoplasm Of Endometrium $95,034
Sensitive Diagnosis $94,977
Chronic Myeloid Leukemia, Bcr/abl-positive, Not Having Achieved Remission $93,883
Malignant Neoplasm Of Unspecified Site Of Unspecified Female Breast $92,906
Spinal Stenosis, Lumbar Region $92,422
Longitudinal Reduction Defect Of Left Femur $89,566
Non-st Elevation (nstemi) Myocardial Infarction $89,009
Rheumatoid Arthritis Without Rheumatoid Factor, Multiple Sites $88,483
Multiple Sclerosis $88,358
Sensitive Diagnosis $88,159
Sensitive Diagnosis $87,973
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $87,480
Multiple Sclerosis $87,447
Other Spondylosis With Radiculopathy, Lumbar Region $87,235
Anemia, Unspecified $87,108
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 90 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsType 1 Diabetes Mellitus Without Complications $86,448
Malignant Neoplasm Of Prostate $83,803
Pain In Left Knee $83,020
Spinal Stenosis, Cervical Region $82,698
Calculus Of Ureter $81,411
Atherosclerosis Of Native Arteries Of Left Leg With Ulceration Of Other Part Of Foot $80,999
Malignant Neoplasm Of Prostate $80,349
Sepsis, Unspecified Organism $80,102
Multiple Sclerosis $79,230
Type 1 Diabetes Mellitus With Hyperglycemia $78,533
Bilateral Primary Osteoarthritis Of Knee $77,990
Neuromuscular Dysfunction Of Bladder, Unspecified $77,900
Encounter For Screening Mammogram For Malignant Neoplasm Of Breast $77,247
Malignant Neoplasm Of Upper Lobe, Right Bronchus Or Lung $76,826
Other Instability, Right Foot $76,510
Abscess Of Lung With Pneumonia $76,397
Endometriosis Of Pelvic Peritoneum $75,632
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 91 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSpinal Stenosis, Lumbar Region $74,437
Sensitive Diagnosis $72,205
Unspecified Abdominal Pain $72,081
Pseudarthrosis After Fusion Or Arthrodesis $71,575
Fistula Of Stomach And Duodenum $70,548
Malignant Neoplasm Of Prostate $69,787
Neuromuscular Dysfunction Of Bladder, Unspecified $69,762
Occlusion And Stenosis Of Left Carotid Artery $69,322
Crohn's Disease Of Small Intestine Without Complications $67,803
Retention Of Urine, Unspecified $66,484
Sensitive Diagnosis $66,345
Unilateral Primary Osteoarthritis, Right Knee $65,542
Malignant Neoplasm Of Endometrium $64,886
Intramural Leiomyoma Of Uterus $64,796
Sensitive Diagnosis $63,285
Encounter For Antineoplastic Radiation Therapy $62,728
Congenital Malformations Of Intestinal Fixation $61,532
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 92 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSubserosal Leiomyoma Of Uterus $60,620
Sepsis, Unspecified Organism $59,854Pain Due To Internal Orthopedic Prosthetic Devices, Implants And Grafts, InitialEncounter $59,660
Abdominal Aortic Aneurysm, Without Rupture $59,623Pain Due To Internal Orthopedic Prosthetic Devices, Implants And Grafts, InitialEncounter $59,281
Encounter For Screening For Malignant Neoplasm Of Colon $58,526
Other Spondylosis With Radiculopathy, Cervical Region $58,417
Malignant Neoplasm Of Appendix $57,994
Sensitive Diagnosis $57,663
Type 1 Diabetes Mellitus With Ketoacidosis Without Coma $57,560
Diaphragmatic Hernia Without Obstruction Or Gangrene $57,362
Malignant Carcinoid Tumor Of The Bronchus And Lung $57,357
Cleft Palate, Unspecified $57,275
Rheumatoid Arthritis, Unspecified $57,183
Sensitive Diagnosis $57,013
Encounter For Antineoplastic Radiation Therapy $56,604
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 93 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnilateral Post-traumatic Osteoarthritis, Right Knee $56,370
Unspecified Hydronephrosis $55,877
Unspecified Iridocyclitis $55,726
Diarrhea, Unspecified $55,642
Osteomyelitis, Unspecified $55,575
Other Pneumothorax $55,544
Malignant Neoplasm Of Frontal Lobe $55,242
Inflammatory Polyarthropathy $54,984
Rheumatoid Arthritis, Unspecified $54,688
Vesicointestinal Fistula $54,384
Sensitive Diagnosis $54,269
Sensitive Diagnosis $54,032
Non-st Elevation (nstemi) Myocardial Infarction $53,636
Complete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $53,482
Infection Following A Procedure, Initial Encounter $53,229
Unilateral Primary Osteoarthritis, Left Hip $53,158
Non-st Elevation (nstemi) Myocardial Infarction $53,005
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 94 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsMultiple Sclerosis $52,852
Juvenile Rheumatoid Polyarthritis (seronegative) $52,740
Radiculopathy, Cervical Region $52,556
Chronic Ethmoidal Sinusitis $52,542
Precocious Puberty $52,532
Osteoarthritis Of Knee, Unspecified $52,490
Cystic Fibrosis, Unspecified $52,037
Plantar Fascial Fibromatosis $52,016Atherosclerotic Heart Disease Of Native Coronary Artery With Other Forms Of AnginaPectoris $51,551
Malignant Neoplasm Of Cervix Uteri, Unspecified $51,320
Sensitive Diagnosis $51,053
Psoriasis Vulgaris $50,925
Gastrostomy Status $50,754
Obstructive Sleep Apnea (adult) (pediatric) $50,670
Sprain Of Anterior Cruciate Ligament Of Left Knee, Initial Encounter $50,366
Calculus Of Gallbladder With Acute Cholecystitis With Obstruction $50,212
Sensitive Diagnosis $49,892
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 95 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsAcute On Chronic Systolic (congestive) Heart Failure $48,854
Malignant Neoplasm Of Unspecified Site Of Left Female Breast $48,639
Acute Serous Otitis Media, Bilateral $48,277
Unilateral Primary Osteoarthritis, Right Hip $48,034
Other Specified Rheumatoid Arthritis, Multiple Sites $47,462
Migraine Without Aura, Intractable, Without Status Migrainosus $47,330
Streptococcus B Carrier State Complicating Childbirth $47,122
Benign Neoplasm Of Pituitary Gland $47,032
Unilateral Primary Osteoarthritis, Right Knee $46,947
Rheumatoid Arthritis With Rheumatoid Factor, Unspecified $46,928
Arthropathic Psoriasis, Unspecified $46,604
Non-st Elevation (nstemi) Myocardial Infarction $46,168
Cerebral Infarction, Unspecified $46,140
Unilateral Primary Osteoarthritis, Right Knee $45,946
Sensitive Diagnosis $45,862
Diaphragmatic Hernia Without Obstruction Or Gangrene $45,768
Other Cervical Disc Degeneration, Mid-cervical Region $45,652
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 96 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnilateral Primary Osteoarthritis, Left Knee $45,591
Stenosis Of Other Cardiac Prosthetic Devices, Implants And Grafts, Initial Encounter $45,127
Arthropathic Psoriasis, Unspecified $44,328
Malignant Neoplasm Of Prostate $44,313
Unilateral Primary Osteoarthritis, Right Hip $44,286
Sensitive Diagnosis $44,076
Sensitive Diagnosis $43,897
Calculus Of Kidney $43,861
Primary Pulmonary Hypertension $43,748
Other Cyst Of Bone, Other Site $43,626
Sensitive Diagnosis $43,607
Embolism And Thrombosis Of Arteries Of The Lower Extremities $43,413
Unilateral Primary Osteoarthritis, Left Hip $43,312
Acute Respiratory Failure With Hypoxia $43,311
Edema, Unspecified $43,294
Crohn's Disease Of Small Intestine With Other Complication $43,253
Encounter For Screening For Malignant Neoplasm Of Colon $42,445
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 97 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Antineoplastic Immunotherapy $42,387
Intestinal Adhesions [bands] With Obstruction (postinfection) $42,345
Pericardial Effusion (noninflammatory) $41,976
Type 1 Diabetes Mellitus With Hyperglycemia $41,970
Other Chronic Pain $41,738
Benign Neoplasm Of Right Ovary $41,538
Lesion Of Plantar Nerve, Right Lower Limb $41,495
Gastro-esophageal Laceration-hemorrhage Syndrome $41,403
Sepsis Due To Hemophilus Influenzae $40,922
Osteoarthritis Of Knee, Unspecified $40,764
Other Specified Diabetes Mellitus With Ketoacidosis Without Coma $40,596Strain Of Other Specified Muscles, Fascia And Tendons At Thigh Level, Right Thigh,Initial Encounter $40,567
Benign Neoplasm Of Parathyroid Gland $40,468
Pseudarthrosis After Fusion Or Arthrodesis $40,397
Unspecified Atrial Flutter $40,351
Other Cervical Disc Displacement, Mid-cervical Region $40,101
Family History Of Ischemic Heart Disease And Other Diseases Of The Circulatory System $39,998
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 98 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $39,866
Unilateral Primary Osteoarthritis, Right Knee $39,772
Arthropathic Psoriasis, Unspecified $39,542
Induration Penis Plastica $39,232
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $39,079
Unspecified Fracture Of Lower End Of Right Tibia, Initial Encounter For Closed Fracture $39,059
Sensitive Diagnosis $39,048
Unspecified Sequelae Of Unspecified Cerebrovascular Disease $38,954
Osteoarthritis Of Knee, Unspecified $38,952
Morbid (severe) Obesity Due To Excess Calories $38,717
Hydronephrosis With Renal And Ureteral Calculous Obstruction $38,714
Sensitive Diagnosis $38,556
Benign Neoplasm, Unspecified Site $38,503
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $38,452
Esophageal Varices Without Bleeding $38,247
Unspecified Cataract $38,164
Sensitive Diagnosis $38,116
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 99 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsMalignant Neoplasm Of Endometrium $38,073
Unilateral Primary Osteoarthritis, Right Hip $37,958
Other Internal Derangements Of Left Knee $37,935
Unilateral Primary Osteoarthritis, Right Knee $37,854
Other Cervical Disc Displacement, Mid-cervical Region $37,738
Sensitive Diagnosis $37,724
Infection Following A Procedure, Initial Encounter $37,718
Unilateral Primary Osteoarthritis, Left Knee $37,657
Other Chest Pain $37,584
Paroxysmal Atrial Fibrillation $37,359
Sensitive Diagnosis $37,256
Dissection Of Other Specified Artery $36,824
Sensitive Diagnosis $36,706
Precocious Puberty $36,671
Other Acute Postprocedural Pain $36,550
Other Specified Types Of Non-hodgkin Lymphoma, Extranodal And Solid Organ Sites $36,434
Unilateral Primary Osteoarthritis, Left Hip $36,220
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 100 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsExcessive And Frequent Menstruation With Irregular Cycle $35,899
Delayed Milestone In Childhood $35,893
Streptococcal Sepsis, Unspecified $35,780
Osteoarthritis Of Knee, Unspecified $35,725
Leiomyoma Of Uterus, Unspecified $35,633
Sensitive Diagnosis $35,471
Type 2 Diabetes Mellitus Without Complications $35,469
Unilateral Primary Osteoarthritis, Left Hip $35,395
Other Secondary Cataract, Left Eye $35,301
Other Ascites $35,206
Other Specified Disorders Of Eyelid $34,988
Morbid (severe) Obesity Due To Excess Calories $34,928
Excessive And Frequent Menstruation With Irregular Cycle $34,822
End Stage Renal Disease $34,679
Leiomyoma Of Uterus, Unspecified $34,564
Bilateral Primary Osteoarthritis Of Knee $34,549
Unilateral Primary Osteoarthritis, Left Knee $34,464
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 101 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsPoisoning By Propionic Acid Derivatives, Intentional Self-harm, Initial Encounter $34,448
Other Noninflammatory Disorders Of Ovary, Fallopian Tube And Broad Ligament $34,434
Dizziness And Giddiness $34,010
Dry Eye Syndrome Of Bilateral Lacrimal Glands $33,991
Sensitive Diagnosis $33,864
Guillain-barre Syndrome $33,828
Rheumatoid Arthritis With Rheumatoid Factor, Unspecified $33,669
Acute Appendicitis With Generalized Peritonitis $33,646
Malignant Neoplasm Of Thyroid Gland $33,644
Malignant Neoplasm Of Prostate $33,417
Encounter For Therapeutic Drug Level Monitoring $33,408
Unspecified Atrial Fibrillation $33,183
Rheumatoid Arthritis Without Rheumatoid Factor, Multiple Sites $33,106
Sprain Of Anterior Cruciate Ligament Of Right Knee, Initial Encounter $33,040
Unilateral Primary Osteoarthritis, Right Knee $33,004
Sensitive Diagnosis $32,922
Unilateral Primary Osteoarthritis, Right Knee $32,879
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 102 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsAnemia, Unspecified $32,869Displaced Intraarticular Fracture Of Right Calcaneus, Initial Encounter For ClosedFracture $32,769
Unilateral Primary Osteoarthritis, Right Knee $32,620
Unilateral Primary Osteoarthritis, Right Knee $32,548
Intervertebral Disc Disorders With Radiculopathy, Lumbar Region $32,391
Disruptive Mood Dysregulation Disorder $32,292
Displacement Of Intraocular Lens, Initial Encounter $32,203
Unilateral Primary Osteoarthritis, Left Knee $32,145
Osteoarthritis Of Knee, Unspecified $32,106
Chronic Ethmoidal Sinusitis $32,046
Infections Of Kidney In Pregnancy, Third Trimester $32,014
Benign Neoplasm Of Left Ovary $31,995
Sensorineural Hearing Loss, Bilateral $31,850
Unilateral Primary Osteoarthritis, Left Knee $31,780
Other Specified Diseases Of Intestine $31,581
Sensitive Diagnosis $31,578
Ulcerative (chronic) Pancolitis Without Complications $31,494
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 103 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsVascular Disorder Of Intestine, Unspecified $31,372
Sensitive Diagnosis $31,275
Benign Neoplasm Of Ascending Colon $31,242
Sensitive Diagnosis $31,204
Bilateral Primary Osteoarthritis Of Knee $31,185
Maternal Care For Breech Presentation, Fetus 1 $31,133
Sensitive Diagnosis $30,990
Unilateral Primary Osteoarthritis, Right Knee $30,652
Supraventricular Tachycardia $30,526
Unspecified Lump In Breast $30,219
Unilateral Primary Osteoarthritis, Right Hip $30,195
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $30,162
Unspecified Osteoarthritis, Unspecified Site $30,128
Atypical Atrial Flutter $30,121
Incisional Hernia Without Obstruction Or Gangrene $30,120
Incomplete Rotator Cuff Tear Or Rupture Of Left Shoulder, Not Specified As Traumatic $30,077
Pre-existing Type 2 Diabetes Mellitus, In Childbirth $29,908
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 104 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsHyperlipidemia, Unspecified $29,895Other Generalized Epilepsy And Epileptic Syndromes, Not Intractable, Without StatusEpilepticus $29,894
Obstructed Labor Due To Breech Presentation, Fetus 1 $29,801
Dermatochalasis Of Right Upper Eyelid $29,750
Sensitive Diagnosis $29,698
Malignant Neoplasm Of Lower-outer Quadrant Of Left Female Breast $29,634
Thrombotic Microangiopathy $29,564
Chronic Or Unspecified Gastrojejunal Ulcer With Hemorrhage $29,490
Bilateral Inguinal Hernia, Without Obstruction Or Gangrene, Not Specified As Recurrent $29,477
Unspecified Abnormalities Of Gait And Mobility $29,309
Morbid (severe) Obesity Due To Excess Calories $29,206
Encounter For Other Preprocedural Examination $29,127
Sensitive Diagnosis $28,995
Primary Osteoarthritis, Left Shoulder $28,968Other Intraarticular Fracture Of Lower End Of Right Radius, Initial Encounter For ClosedFracture $28,963
Sensitive Diagnosis $28,955
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 105 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $28,857
Deviated Nasal Septum $28,815
Sensitive Diagnosis $28,626
Unilateral Primary Osteoarthritis, Right Hip $28,569
Other Abnormal Involuntary Movements $28,558
Unilateral Inguinal Hernia, Without Obstruction Or Gangrene, Not Specified As Recurrent $28,523Displaced Fracture Of Lateral Malleolus Of Left Fibula, Initial Encounter For ClosedFracture $28,349
Respiratory Distress Of Newborn, Unspecified $28,332
Morbid (severe) Obesity Due To Excess Calories $28,208
Hypothyroidism, Unspecified $28,033
Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Left Cerebellar Artery $27,968
Sensitive Diagnosis $27,839
Benign Neoplasm Of Left Ovary $27,831
Right Lower Quadrant Pain $27,612
Sensitive Diagnosis $27,608
Benign Lipomatous Neoplasm Of Intra-abdominal Organs $27,600
Headache $27,503
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 106 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnilateral Primary Osteoarthritis, Right Knee $27,442
Neoplasm Of Uncertain Behavior Of Left Ovary $27,268
Unilateral Primary Osteoarthritis, Left Knee $27,221
Ganglion, Right Wrist $27,196
Incomplete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $27,105
Sensitive Diagnosis $27,069
Sensitive Diagnosis $27,048
Sensitive Diagnosis $27,037
Osteoarthritis Of Knee, Unspecified $27,036
Sensitive Diagnosis $26,922
Other Iron Deficiency Anemias $26,826
Calculus Of Ureter $26,814
Sensitive Diagnosis $26,765
Carpal Tunnel Syndrome, Right Upper Limb $26,738
Right Upper Quadrant Pain $26,724
Cervical Shortening, Second Trimester $26,700
Other Specified Diseases Of Gallbladder $26,599
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 107 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsMalignant Neoplasm Of Left Ovary $26,557
Spondylosis Without Myelopathy Or Radiculopathy, Lumbar Region $26,451
Other Specified Diseases Of Gallbladder $26,395
Calculus Of Gallbladder And Bile Duct With Cholecystitis, Unspecified, With Obstruction $26,331
Other Postprocedural Complications And Disorders Of Nervous System $26,297
Urticaria, Unspecified $26,278
Morbid (severe) Obesity Due To Excess Calories $26,231
Ankylosing Spondylitis Of Multiple Sites In Spine $25,984
Persistent Atrial Fibrillation $25,933
Obstructive Sleep Apnea (adult) (pediatric) $25,730
Sensitive Diagnosis $25,714
Unilateral Primary Osteoarthritis, Left Hip $25,702
Sensitive Diagnosis $25,667
Parkinson's Disease $25,600
Chronic Or Unspecified Duodenal Ulcer With Perforation $25,584
Displaced Fracture Of Shaft Of Left Clavicle, Initial Encounter For Closed Fracture $25,543
Other Spondylosis With Radiculopathy, Lumbar Region $25,537
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 108 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsPrecocious Puberty $25,514
Sensitive Diagnosis $25,497
Sensitive Diagnosis $25,410
Lumbago With Sciatica, Right Side $25,401
Sensitive Diagnosis $25,377
Obstructive Sleep Apnea (adult) (pediatric) $25,328
Alcoholic Hepatitis With Ascites $25,210
Hydronephrosis With Renal And Ureteral Calculous Obstruction $25,182Atherosclerotic Heart Disease Of Native Coronary Artery With Unspecified AnginaPectoris $25,094
Calculus Of Kidney With Calculus Of Ureter $25,046
Sensitive Diagnosis $25,031
Unspecified Dislocation Of Right Acromioclavicular Joint, Initial Encounter $25,010
Total $25,020,710
Total Above $25,000 $15,470,710
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2018 12:00:0Run Date: 02/12/2018
© Copyright 2018 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 109 of 109
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Expenditure Summary
Service Category Claims PMPMAggregate
PMPMVariance in
PMPMPMPMTrend
Professional $21,284,758 $233.56 $172.17 35.65% 12.19%
Hospital IP $9,167,229 $100.59 $91.03 10.51% 16.34%
Hospital OP $10,562,345 $115.90 $103.74 11.72% 1.35%
Pharmacy $9,298,655 $102.04 $79.08 29.02% 3.06%
DME, Transportation, Other $1,135,349 $12.46 $10.98 13.45% 16.12%
Preventive/Accidental Dental $0 $0.00 $1.39 -100.00% 0.00%
Total $51,448,336 $564.55 $458.40 23.16% 8.83%
All Packages/All Sites YTD Qtrly
Claims include IBNR
Note: The Aggregate PMPM for Preventive Dental services reflects the cost for coverage of children only.
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
100_Ex_Expenditure_SummaryReport Id: 43735
Page 1 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Expenditure Summary
Service Category Claims PMPMAggregate
PMPMVariance in
PMPM
Professional $18,963,874 $208.18 $163.09 27.65%
Hospital IP $7,876,114 $86.46 $84.93 1.80%
Hospital OP $10,417,203 $114.36 $99.67 14.74%
Pharmacy $9,019,153 $99.01 $76.16 30.00%
DME, Transportation, Other $977,133 $10.73 $10.18 5.39%
Preventive/Accidental Dental $0 $0.00 $1.30 -100.00%
Total $47,253,477 $518.74 $435.33 19.16%
All Packages/All Sites YTD Qtrly
Claims include IBNR
Note: The Aggregate PMPM for Preventive Dental services reflects the cost for coverage of children only.
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
100_Ex_Expenditure_SummaryReport Id: 43735
Page 2 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Per Member Per Month Comparisons
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
100_Ex_Expenditure_SumReport Id: 43735
Page 3 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional Utilization by Major Practice Category
Major Practice Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid PerUnit PMPM
Variancein PMPM
PMPMTrend
Orthopedic and Arthritic Conditions $3,136,694.74 10.369 $39.83 $34.42 10.293 $33.12 $28.41 21.15% 1.06%Cancer $2,201,522.91 5.630 $51.49 $24.16 5.372 $31.70 $14.19 70.20% 50.25%Psychiatry $1,823,217.67 3.172 $75.68 $20.01 2.797 $62.19 $14.50 38.01% 4.87%Cardiology $1,634,608.38 2.758 $78.04 $17.94 2.183 $52.14 $9.48 89.11% 13.83%Gastroenterology $1,235,437.78 4.251 $38.27 $13.56 3.745 $36.16 $11.29 20.13% 26.73%Endocrinology $1,228,447.90 6.170 $26.22 $13.48 4.684 $22.42 $8.75 54.05% 6.31%Preventive and Administrative Care $1,219,519.81 2.666 $60.24 $13.38 2.824 $56.01 $13.18 1.50% 10.58%Otolaryngology $1,023,744.86 2.530 $53.29 $11.23 2.926 $38.80 $9.46 18.72% -1.40%Gynecology $933,326.41 4.914 $25.01 $10.24 3.924 $22.75 $7.44 37.67% 21.18%Dermatology $902,698.03 1.886 $63.01 $9.91 1.780 $52.57 $7.80 27.06% 6.79%Ophthalmology $796,070.07 1.465 $71.56 $8.74 1.433 $56.04 $6.69 30.52% 19.56%Neurology $759,152.97 2.417 $41.36 $8.33 2.312 $36.11 $6.96 19.77% -1.42%Obstetrics $718,725.83 1.825 $51.85 $7.89 1.957 $47.72 $7.78 1.35% 8.83%Pulmonology $454,462.93 0.985 $60.73 $4.99 1.067 $44.18 $3.93 27.01% 3.53%Urology $386,761.52 1.537 $33.13 $4.24 1.383 $29.15 $3.36 26.34% 22.90%Isolated Signs/Symptoms $314,271.67 0.949 $43.62 $3.45 0.960 $38.43 $3.07 12.15% 3.60%Hepatology $251,701.36 1.045 $31.70 $2.76 0.723 $27.82 $1.68 64.77% 14.05%Other $212,137.14 0.739 $37.77 $2.33 1.183 $21.60 $2.13 9.30% -17.96%Nephrology $137,577.22 0.826 $21.92 $1.51 0.387 $30.55 $0.99 53.11% 9.42%Hematology $124,696.71 2.104 $7.80 $1.37 0.772 $15.04 $0.97 41.47% -8.05%Chemical dependency $122,733.78 0.256 $63.20 $1.35 0.288 $38.04 $0.91 47.65% -8.78%Neonatology $114,268.93 0.088 $171.06 $1.25 0.145 $112.41 $1.36 -7.66% 7.76%Infectious diseases $97,371.44 0.172 $74.39 $1.07 0.773 $28.10 $1.81 -41.01% -7.76%Late effects/Complications $65,572.86 0.200 $43.25 $0.72 0.201 $29.22 $0.49 47.30% 50.00%Total $19,894,723 58.954 $44.44 $218.31 54.112 $36.95 $166.62 31.02% 11.04%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 4 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Professional Utilization by Major Practice Category
Major Practice Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid PerUnit PMPM
Variancein PMPM
Orthopedic and Arthritic Conditions $3,102,315.39 10.750 $38.02 $34.06 10.321 $31.27 $26.90 26.62%Psychiatry $1,738,283.00 2.793 $81.98 $19.08 2.739 $57.78 $13.19 44.68%Cancer $1,465,128.52 4.603 $41.93 $16.08 5.225 $34.75 $15.13 6.29%Cardiology $1,435,884.91 2.378 $79.55 $15.76 2.206 $49.34 $9.07 73.79%Endocrinology $1,154,916.97 5.963 $25.52 $12.68 4.833 $21.50 $8.66 46.40%Preventive and Administrative Care $1,102,379.28 2.513 $57.80 $12.10 4.518 $37.61 $14.16 -14.53%Otolaryngology $1,037,773.49 3.131 $43.67 $11.39 2.956 $37.88 $9.33 22.09%Gastroenterology $974,546.10 2.565 $50.06 $10.70 2.923 $41.96 $10.22 4.66%Dermatology $845,467.34 1.760 $63.29 $9.28 1.686 $48.02 $6.75 37.56%Gynecology $770,013.48 4.272 $23.74 $8.45 2.187 $26.75 $4.88 73.36%Neurology $769,457.60 2.327 $43.57 $8.45 2.364 $32.15 $6.33 33.35%Ophthalmology $665,512.27 1.239 $70.77 $7.31 1.467 $52.22 $6.38 14.46%Obstetrics $660,490.92 1.744 $49.89 $7.25 1.892 $47.89 $7.55 -3.96%Pulmonology $439,432.67 1.032 $56.11 $4.82 1.076 $41.99 $3.76 28.13%Urology $314,668.55 1.380 $30.04 $3.45 1.296 $28.95 $3.13 10.46%Isolated Signs/Symptoms $302,917.23 0.981 $40.69 $3.33 0.982 $39.57 $3.24 2.68%Other $258,721.50 1.339 $25.46 $2.84 1.145 $20.75 $1.98 43.48%Hepatology $220,085.80 1.028 $28.21 $2.42 0.702 $26.44 $1.55 56.14%Hematology $135,905.43 1.487 $12.04 $1.49 0.636 $18.00 $0.95 56.30%Chemical dependency $135,253.44 0.445 $40.06 $1.48 0.323 $39.11 $1.05 41.02%Nephrology $125,267.40 1.679 $9.83 $1.38 0.366 $27.93 $0.85 61.56%Neonatology $105,843.79 0.071 $196.37 $1.16 0.138 $97.90 $1.12 3.39%Infectious diseases $105,300.16 0.443 $31.30 $1.16 0.857 $19.87 $1.42 -18.50%Late effects/Complications $43,443.71 0.158 $36.11 $0.48 0.198 $26.60 $0.44 8.43%Total $17,909,009 56.077 $42.07 $196.60 53.037 $35.76 $158.05 24.39%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 5 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Prior Aggregate
Report Period: 2/1/2017 12:00:00 ARun Date: 02/17/2017
© Copyright 2017 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 6 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional Utilization by Service Category
Service Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid perUnit PMPM
Variance inPMPM
PMPMTREND
Office Visit $4,252,744 3.457 $161.97 $46.67 3.086 $120.72 $31.05 50.31% 8.94%
Surgery $3,897,323 18.709 $27.43 $42.77 17.781 $24.87 $36.84 16.07% 10.40%
Radiology / Lab / Pathology $3,637,518 11.007 $43.52 $39.91 8.766 $38.20 $27.91 43.04% 22.35%
Injections / Immunizations / IV Therapy $2,692,177 16.350 $21.68 $29.54 14.801 $16.14 $19.91 48.40% 11.68%
Hospital / Institutional Visits $1,074,584 0.511 $277.10 $11.79 0.511 $222.61 $9.48 24.36% 9.88%
Other Visits / Procedures $1,064,533 1.902 $73.71 $11.68 1.877 $55.70 $8.71 34.09% 11.98%
Mental Health $952,127 1.847 $67.90 $10.45 1.725 $56.43 $8.11 28.78% 0.97%
Physical Exam $801,627 0.509 $207.19 $8.80 0.531 $205.17 $9.08 -3.07% 2.56%
Physical Therapy / Chiropractic $483,054 2.653 $23.97 $5.30 2.949 $21.51 $5.29 0.29% 6.85%
Maternity Care and Delivery $374,089 0.067 $732.07 $4.10 0.054 $961.86 $4.36 -5.88% 9.63%
Routine Eye Care $320,026 0.343 $122.90 $3.51 0.334 $103.75 $2.89 21.55% 3.54%
Allergy / Dermatology $137,320 0.848 $21.31 $1.51 0.716 $17.22 $1.03 46.53% 0.67%
Chemotherapy $93,673 0.046 $267.64 $1.03 0.048 $177.49 $0.71 45.29% 11.96%
Consults $46,683 0.048 $127.55 $0.51 0.036 $144.85 $0.43 18.47% -8.93%
Supplies $35,626 0.563 $8.33 $0.39 0.731 $5.49 $0.33 16.89% -2.50%
E-Visits $19,416 0.064 $40.12 $0.21 0.078 $51.58 $0.33 -36.26% 10.53%
Chemical Health $12,206 0.030 $53.77 $0.13 0.087 $22.62 $0.16 -18.73% -40.91%
Total $19,894,723 58.954 $44.44 $218.31 54.112 $36.95 $166.62 31.02% 11.04%
All Packages/All Sites YTD Qtrly
AggregateCurrent Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
120_Ex_Professional_by_CategoryReport Id: 43735
Page 7 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Professional Utilization by Service Category
Service Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid perUnit PMPM
Variance inPMPM
Office Visit $3,902,310 3.437 $149.57 $42.84 3.072 $115.87 $29.66 44.41%
Surgery $3,528,643 16.751 $27.75 $38.74 17.486 $23.72 $34.57 12.06%
Radiology / Lab / Pathology $2,971,193 10.216 $38.31 $32.62 8.365 $39.46 $27.51 18.57%
Injections / Immunizations / IV Therapy $2,409,125 16.384 $19.37 $26.45 14.600 $15.61 $18.99 39.24%
Hospital / Institutional Visits $977,685 0.508 $253.68 $10.73 0.500 $205.06 $8.55 25.54%
Other Visits / Procedures $949,705 1.906 $65.64 $10.43 1.831 $53.28 $8.13 28.23%
Mental Health $943,232 1.635 $76.01 $10.35 1.732 $49.86 $7.20 43.90%
Physical Exam $781,186 0.482 $213.32 $8.58 0.506 $205.48 $8.66 -1.01%
Physical Therapy / Chiropractic $451,625 2.559 $23.24 $4.96 2.826 $21.03 $4.95 0.09%
Maternity Care and Delivery $340,251 0.048 $929.65 $3.74 0.052 $934.22 $4.09 -8.60%
Routine Eye Care $308,786 0.335 $121.52 $3.39 0.335 $102.50 $2.86 18.40%
Allergy / Dermatology $136,746 0.957 $18.81 $1.50 0.679 $16.58 $0.94 60.05%
Chemotherapy $83,423 0.045 $243.22 $0.92 0.048 $180.99 $0.72 27.72%
Consults $51,120 0.049 $138.54 $0.56 0.032 $154.92 $0.42 34.77%
Supplies $36,499 0.631 $7.62 $0.40 0.824 $4.78 $0.33 21.97%
Chemical Health $20,225 0.079 $33.93 $0.22 0.089 $22.75 $0.17 31.80%
E-Visits $17,256 0.055 $41.18 $0.19 0.059 $62.48 $0.31 -38.18%
Total $17,909,009 56.077 $42.07 $196.60 53.037 $35.76 $158.05 24.39%
All Packages/All Sites YTD Qtrly
AggregatePrior Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
120_Ex_Professional_by_CategoryReport Id: 43735
Page 8 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
120_Ex_Professional_by_Report Id: 43735
Page 9 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Inpatient Utilization by Major Practice Category
Major Practice Category ClaimsAdmits
per 1000Paid per
AdmitDays
per 1000 PMPMAdmits per
1000Paid Per
AdmitDays
per 1000 PMPMVariancein PMPM
PMPMTrend
Orthopedic and Arthritic Conditions $1,673,183 9.1 $24,249 33.2 $18.36 7.9 $21,023 34.9 $13.87 32.41% 79.47%Cardiology $1,277,000 4.5 $37,559 17.8 $14.01 4.8 $27,763 23.1 $11.05 26.81% 62.34%Neurology $874,402 3.7 $31,229 24.6 $9.59 3.5 $31,238 28.9 $9.18 4.47% -34.32%Obstetrics $819,661 12.5 $8,628 36.9 $8.99 13.6 $7,472 34.3 $8.45 6.41% 43.84%Endocrinology $741,634 3.3 $29,665 16.2 $8.14 2.7 $26,078 13.4 $5.84 39.44% 70.65%Gastroenterology $587,002 4.7 $16,306 16.5 $6.44 3.5 $14,629 13.4 $4.25 51.58% 77.90%Neonatology $437,502 9.7 $5,912 28.2 $4.80 11.1 $5,397 30.4 $5.00 -4.07% 23.71%Cancer $434,009 2.1 $27,126 6.6 $4.76 3.3 $27,983 17.3 $7.75 -38.54% 1.71%Pulmonology $347,398 2.8 $16,543 15.9 $3.81 2.8 $19,061 12.9 $4.47 -14.81% 147.40%Psychiatry $242,824 2.5 $12,780 14.2 $2.66 4.1 $13,332 37.3 $4.56 -41.61% -41.54%Hepatology $206,603 2.6 $10,330 8.4 $2.27 1.0 $18,183 3.8 $1.48 53.58% -53.58%Chemical dependency $186,151 2.9 $8,461 29.0 $2.04 2.3 $12,465 32.0 $2.34 -12.75% -42.54%Urology $179,370 1.1 $22,421 3.7 $1.97 0.8 $14,058 2.6 $0.90 118.54% 198.48%Infectious diseases $132,368 0.8 $22,061 3.0 $1.45 1.3 $15,407 6.4 $1.70 -14.75% 245.24%Gynecology $124,409 1.2 $13,823 2.2 $1.37 0.7 $14,383 1.7 $0.88 54.50% 61.18%Nephrology $86,181 1.2 $9,576 4.1 $0.95 0.8 $32,235 5.7 $2.11 -55.13% -73.76%Late effects/Complications $60,685 0.5 $15,171 2.5 $0.67 0.6 $16,129 2.0 $0.84 -20.94% -8.22%Otolaryngology $34,364 0.3 $17,182 0.8 $0.38 0.7 $18,407 2.7 $1.01 -62.65% -56.82%Dermatology $28,085 0.3 $14,042 0.8 $0.31 0.6 $10,505 3.0 $0.49 -36.93% 82.35%Other $14,707 0.1 $14,707 0.4 $0.16 0.1 $34,732 0.9 $0.21 -24.37% 0.00%Ophthalmology $9,718 0.1 $9,718 0.1 $0.11 0.1 $11,449 0.2 $0.07 51.62% -90.35%Hematology $9,069 0.1 $9,069 0.4 $0.10 0.5 $16,356 1.9 $0.63 -84.24% -95.82%Isolated Signs/Symptoms $0 0.0 $0 0.0 $0.00 0.0 $13,307 0.1 $0.04 -100.00% -100.00%Preventive and Administrative Care $0 0.0 $0 0.0 $0.00 0.5 $25,214 2.8 $1.02 -100.00% -100.00%Total $8,506,323 66.1 $16,945 265.5 $93.34 67.2 $15,752 311.8 $88.15 5.89% 13.59%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 10 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Inpatient Utilization by Major Practice Category
Major Practice Category ClaimsAdmits
per 1000Paid per
AdmitDays
per 1000 PMPMAdmits per
1000Paid Per
AdmitDays
per 1000 PMPMVariancein PMPM
Neurology $1,330,120 4.9 $35,949 44.3 $14.60 3.8 $24,855 28.5 $7.86 85.89%Orthopedic and Arthritic Conditions $931,938 7.0 $17,584 27.8 $10.23 8.2 $20,228 37.5 $13.75 -25.62%Cardiology $785,963 5.8 $17,863 19.9 $8.63 5.1 $23,618 24.4 $9.98 -13.58%Obstetrics $569,673 11.3 $6,624 25.8 $6.25 13.1 $6,843 32.7 $7.47 -16.26%Hepatology $445,188 1.3 $44,519 6.6 $4.89 0.9 $20,610 3.9 $1.53 219.00%Endocrinology $434,545 4.3 $13,168 9.5 $4.77 3.0 $21,002 15.4 $5.26 -9.28%Cancer $425,955 3.2 $17,748 15.1 $4.68 3.8 $26,301 17.8 $8.26 -43.42%Psychiatry $414,071 5.9 $9,202 63.9 $4.55 4.7 $11,685 47.8 $4.53 0.24%Neonatology $353,246 7.9 $5,887 21.1 $3.88 10.4 $5,605 29.3 $4.86 -20.28%Nephrology $329,929 2.0 $21,995 7.2 $3.62 0.6 $22,788 3.8 $1.23 195.36%Gastroenterology $329,822 3.2 $13,743 9.4 $3.62 3.5 $14,316 12.4 $4.18 -13.34%Chemical dependency $323,594 4.6 $9,246 39.0 $3.55 2.3 $10,653 29.3 $2.05 72.87%Hematology $217,615 0.8 $36,269 5.5 $2.39 0.4 $28,463 2.8 $1.01 135.96%Pulmonology $140,027 1.7 $10,771 3.7 $1.54 2.6 $14,089 11.5 $3.10 -50.46%Ophthalmology $103,393 0.0 $0 3.2 $1.14 0.1 $64,042 1.0 $0.32 253.31%Otolaryngology $79,726 0.5 $19,932 1.6 $0.88 0.6 $14,215 2.0 $0.71 22.74%Gynecology $77,668 1.1 $9,708 2.1 $0.85 1.1 $12,876 2.5 $1.17 -27.40%Late effects/Complications $66,298 0.8 $11,050 1.3 $0.73 0.6 $13,464 2.0 $0.63 15.08%Urology $60,275 0.8 $10,046 1.4 $0.66 1.1 $11,764 3.6 $1.07 -38.02%Infectious diseases $38,669 0.5 $9,667 1.6 $0.42 1.3 $16,533 6.4 $1.79 -76.34%Dermatology $15,508 0.1 $15,508 0.5 $0.17 0.4 $13,756 1.8 $0.43 -60.09%Isolated Signs/Symptoms $6,285 0.1 $6,285 0.4 $0.07 0.0 $8,558 0.1 $0.02 253.58%Preventive and Administrative Care $5,427 0.3 $2,713 0.8 $0.06 0.6 $21,696 4.5 $1.04 -94.27%Other $0 0.0 $0 0.0 $0.00 0.0 $34,280 0.3 $0.13 -100.00%Total $7,484,934 68.1 $14,478 311.7 $82.17 68.1 $14,516 321.1 $82.40 -0.28%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 11 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Top 10 Inpatient PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Current Aggregate
Report Period: 2/1/2017 12:00:00 ARun Date: 02/17/2017
© Copyright 2017 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 12 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Inpatient Utilization by Service Category
Service Category ClaimsAdmits
per 1000Paid Per
AdmitDays per
1000 PMPMAdmits per
1000Paid per
AdmitDays per
1000 PMPMVariancein PMPM
PMPMTrend
Surgical $4,787,321 19.5 $32,347 74.1 $52.53 16.0 $31,569 61.0 $42.07 24.86% 37.19%
Medical $1,600,847 16.3 $12,910 58.7 $17.57 17.5 $13,841 63.8 $20.20 -13.04% -3.51%
Maternity $837,155 12.9 $8,542 38.4 $9.19 13.5 $7,434 34.5 $8.38 9.66% 27.99%
Newborn $445,243 9.7 $6,017 27.8 $4.89 11.3 $6,787 34.0 $6.39 -23.52% -29.34%
Other Treatments $423,252 0.9 $60,465 5.0 $4.64 0.6 $52,508 2.9 $2.65 75.28% 1,756.00%
Chemical Health $169,640 2.5 $8,928 27.9 $1.86 2.4 $14,608 42.5 $2.93 -36.46% -48.90%
Mental Health $121,582 2.0 $8,105 7.2 $1.33 3.1 $11,866 20.9 $3.04 -56.05% -49.81%
Non-Acute $121,283 2.2 $7,134 26.2 $1.33 2.7 $10,907 52.1 $2.50 -46.73% -73.51%
Total $8,506,323 66.1 $16,945 265.5 $93.34 67.2 $15,752 311.8 $88.15 5.89% 13.59%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Current Year Actual
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
140_Ex_Inpatient_By_CategoryReport Id: 43735
Page 13 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Inpatient Utilization by Service Category
Service Category ClaimsAdmits
per 1000Paid Per
AdmitDays per
1000 PMPMAdmits per
1000Paid per
AdmitDays per
1000 PMPMVariancein PMPM
Surgical $3,487,649 15.9 $28,824 53.5 $38.29 16.7 $27,697 61.4 $38.44 -0.39%
Medical $1,658,952 18.8 $11,601 60.6 $18.21 18.3 $13,091 67.0 $20.02 -9.02%
Maternity $653,913 12.5 $6,883 30.8 $7.18 13.3 $6,885 33.5 $7.64 -6.03%
Newborn $630,491 8.0 $10,336 28.2 $6.92 10.6 $7,136 33.3 $6.30 9.80%
Non-Acute $457,306 4.1 $14,752 43.5 $5.02 2.7 $10,410 52.4 $2.38 110.65%
Chemical Health $331,702 3.4 $12,758 77.7 $3.64 2.4 $13,723 49.7 $2.74 32.84%
Mental Health $241,834 5.0 $6,364 17.1 $2.65 3.7 $9,651 21.6 $2.94 -9.83%
Other Treatments $23,088 0.3 $11,544 0.3 $0.25 0.4 $58,261 2.2 $1.94 -86.93%
Total $7,484,934 68.1 $14,478 311.7 $82.17 68.1 $14,516 321.1 $82.40 -0.28%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Prior Year Actual
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
140_Ex_Inpatient_By_CategoryReport Id: 43735
Page 14 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Inpatient PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
140_Ex_Inpatient_By_CateReport Id: 43735
Page 15 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient Utilization by Major Practice Category
Major Practice Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid Per
Unit PMPMVariancein PMPM
PMPMTrend
Cancer $1,690,627 5,025 $44.30 $18.55 5,501 $32.77 $15.02 23.51% -1.90%Orthopedic and Arthritic Conditions $1,624,817 3,378 $63.34 $17.83 3,154 $63.00 $16.56 7.69% -11.73%Cardiology $1,284,583 3,187 $53.07 $14.10 3,101 $48.99 $12.66 11.35% 3.68%Gastroenterology $642,815 1,749 $48.40 $7.05 2,170 $49.87 $9.02 -21.79% 15.01%Endocrinology $567,954 2,572 $29.08 $6.23 1,604 $37.35 $4.99 24.81% 6.50%Psychiatry $492,073 960 $67.49 $5.40 761 $77.20 $4.90 10.22% -3.23%Gynecology $485,021 1,161 $55.03 $5.32 829 $57.08 $3.94 35.00% 77.33%Nephrology $484,807 5,066 $12.60 $5.32 1,614 $17.72 $2.38 123.23% 40.37%Chemical dependency $396,133 894 $58.33 $4.35 571 $55.75 $2.65 63.82% -32.03%Otolaryngology $361,213 692 $68.71 $3.96 934 $64.74 $5.04 -21.36% -12.00%Neurology $334,921 896 $49.22 $3.68 1,370 $42.42 $4.84 -24.11% -19.65%Pulmonology $266,957 999 $35.20 $2.93 833 $41.35 $2.87 2.03% -2.98%Preventive and Administrative Care $238,441 451 $69.56 $2.62 408 $69.10 $2.35 11.50% 95.52%Urology $218,937 639 $45.09 $2.40 691 $47.74 $2.75 -12.63% 25.65%Ophthalmology $200,469 419 $62.94 $2.20 371 $64.40 $1.99 10.46% 24.29%Dermatology $141,863 443 $42.16 $1.56 473 $51.06 $2.01 -22.62% -7.14%Obstetrics $90,706 165 $72.28 $1.00 237 $71.68 $1.42 -29.81% 28.21%Hepatology $89,725 554 $21.32 $0.98 337 $42.26 $1.19 -17.13% -26.87%Isolated Signs/Symptoms $85,608 163 $69.26 $0.94 230 $66.82 $1.28 -26.53% -22.95%Hematology $85,259 779 $14.42 $0.94 787 $18.60 $1.22 -23.37% -1.05%Infectious diseases $36,891 111 $43.71 $0.40 133 $50.25 $0.56 -27.50% -18.37%Late effects/Complications $31,526 66 $62.93 $0.35 97 $42.71 $0.35 -0.10% -22.22%Neonatology $20,006 43 $60.81 $0.22 161 $34.28 $0.46 -52.16% -37.14%Other $1,833 1 $261.88 $0.02 2 $87.48 $0.02 19.92% -77.78%Total $9,873,188 30,415 $42.74 $108.34 26,371 $45.72 $100.47 7.84% 0.39%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 16 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Outpatient Utilization by Major Practice Category
Major Practice Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid Per
Unit PMPMVariancein PMPM
Orthopedic and Arthritic Conditions $1,839,802 3,156 $76.78 $20.20 3,006 $63.02 $15.79 27.94%Cancer $1,722,414 5,863 $38.70 $18.91 5,566 $31.96 $14.83 27.53%Cardiology $1,239,270 2,844 $57.41 $13.60 2,803 $51.32 $11.99 13.50%Chemical dependency $583,304 720 $106.70 $6.40 546 $60.50 $2.75 132.69%Gastroenterology $558,521 1,468 $50.11 $6.13 2,362 $45.06 $8.87 -30.85%Endocrinology $533,317 3,553 $19.78 $5.85 1,351 $36.13 $4.07 43.89%Psychiatry $508,117 635 $105.42 $5.58 706 $78.76 $4.63 20.37%Neurology $417,013 754 $72.83 $4.58 1,522 $41.01 $5.20 -12.00%Otolaryngology $409,652 910 $59.28 $4.50 939 $63.49 $4.97 -9.47%Nephrology $344,953 3,062 $14.84 $3.79 2,018 $11.56 $1.94 94.87%Pulmonology $275,320 729 $49.72 $3.02 640 $45.88 $2.45 23.44%Gynecology $272,901 802 $44.85 $3.00 850 $48.55 $3.44 -12.90%Urology $173,856 601 $38.09 $1.91 695 $43.92 $2.55 -25.01%Ophthalmology $161,370 290 $73.25 $1.77 480 $53.19 $2.13 -16.74%Dermatology $153,112 343 $58.75 $1.68 547 $39.82 $1.82 -7.44%Hepatology $122,494 490 $32.96 $1.34 549 $32.84 $1.50 -10.53%Preventive and Administrative Care $122,476 232 $69.63 $1.34 609 $58.07 $2.95 -54.39%Isolated Signs/Symptoms $110,845 156 $93.54 $1.22 144 $91.55 $1.10 10.55%Hematology $86,313 813 $13.99 $0.95 1,006 $13.72 $1.15 -17.60%Obstetrics $70,931 172 $54.31 $0.78 386 $43.37 $1.39 -44.12%Infectious diseases $44,247 105 $55.73 $0.49 188 $31.02 $0.49 -0.31%Late effects/Complications $40,593 63 $84.39 $0.45 65 $56.53 $0.30 46.15%Neonatology $31,545 32 $128.75 $0.35 151 $25.06 $0.31 10.04%Other $8,447 6 $191.97 $0.09 11 $32.62 $0.03 209.38%Total $9,830,810 27,800 $46.59 $107.92 27,141 $42.73 $96.64 11.67%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 17 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Prior Aggregate
Report Period: 2/1/2017 12:00:00 ARun Date: 02/17/2017
© Copyright 2017 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 18 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient Utilization by Service Category
Service Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid per
Unit PMPMVariance in
PMPMPMPMTrend
Surgery $3,764,480 8,941 $55.44 $41.31 8,287 $61.13 $42.21 -2.15% -1.97%
Other Treatments $2,050,536 10,851 $24.88 $22.50 8,499 $26.60 $18.84 19.42% 0.90%
Emergency Room $1,392,672 4,061 $45.16 $15.28 3,904 $43.37 $14.11 8.31% 7.00%
Radiology $1,248,459 3,932 $41.81 $13.70 3,099 $43.97 $11.35 20.65% 1.93%
Cardiovascular $491,058 99 $650.41 $5.39 90 $517.12 $3.88 38.75% 25.93%
Physical Therapy / Chiropractic $242,006 512 $62.18 $2.66 614 $67.69 $3.47 -23.37% -3.27%
Lab $206,004 696 $38.97 $2.26 728 $42.41 $2.57 -12.11% 4.15%
Mental Health $179,430 73 $325.64 $1.97 78 $303.49 $1.97 -0.02% -44.51%
Chemical Health $138,124 243 $74.90 $1.52 196 $75.43 $1.23 23.08% -25.49%
Observation/Non-Invasive Procedures $122,170 231 $69.53 $1.34 113 $53.81 $0.51 163.99% 67.50%
Pharmacy, Hospital or Clinic $38,249 775 $6.50 $0.42 763 $4.99 $0.32 32.23% 162.50%
Total $9,873,188 30,415 $42.74 $108.34 26,371 $45.72 $100.47 7.84% 0.39%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Current Year Actual
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
160_Ex_Outpatient_by_CategoryReport Id: 43735
Page 19 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Outpatient Utilization by Service Category
Service Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid per
Unit PMPMVariance in
PMPM
Surgery $3,838,787 8,191 $61.74 $42.14 8,699 $56.24 $40.77 3.38%
Other Treatments $2,031,032 9,868 $27.11 $22.30 8,764 $23.52 $17.18 29.79%
Emergency Room $1,301,171 3,811 $44.98 $14.28 4,051 $39.90 $13.47 6.05%
Radiology $1,224,598 3,249 $49.66 $13.44 2,978 $46.84 $11.62 15.66%
Cardiovascular $389,530 115 $447.22 $4.28 95 $489.64 $3.89 9.92%
Mental Health $323,804 107 $398.28 $3.55 87 $278.96 $2.01 76.56%
Physical Therapy / Chiropractic $250,657 510 $64.77 $2.75 626 $67.67 $3.53 -22.10%
Lab $197,695 716 $36.38 $2.17 700 $37.50 $2.19 -0.84%
Chemical Health $185,791 203 $120.80 $2.04 184 $82.10 $1.26 61.89%
Observation/Non-Invasive Procedures $73,162 121 $79.61 $0.80 123 $40.42 $0.42 93.11%
Pharmacy, Hospital or Clinic $14,584 909 $2.11 $0.16 833 $4.40 $0.31 -47.60%
Total $9,830,810 27,800 $46.59 $107.92 27,141 $42.73 $96.64 11.67%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Prior Year Actual
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
160_Ex_Outpatient_by_CategoryReport Id: 43735
Page 20 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
160_Ex_Outpatient_by_CatReport Id: 43735
Page 21 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Trend Report
Group Actual Current YearMeasure Prior Year Current Year %Change Prior Year Current Year VarianceTotal Pharmacy PMPM (PL+ML) $105.44 $106.94 1.42% $84.25 $86.63 23.45%Rx Paid PMPM (Plan Paid) $93.35 $95.27 2.06% $73.80 $76.54 24.47%Total Pharmacy (PL+ML) $9,604,456 $9,745,424 1.47% Total Prescriptions 30 day Rx 120,267 118,962 -1.09% Total Members w/Rx benefit 7,591 7,594 0.04% Average Ingredient Cost/Rx $76.41 $78.36 2.54% $69.54 $72.09 8.69%Average Generic Ingredient Cost/Rx $25.70 $25.91 0.81% $23.46 $22.60 14.64%Average Brand Ingredient Cost/Rx $491.33 $548.22 11.58% $429.41 $490.76 11.71%Average Brand Ingredient Cost/Rx(Without Specialty Drugs) $297.45 $320.78 7.84% $262.78 $287.31 11.65%
Average Brand Ingredient Cost/Rx(Specialty Drugs only) $4,645.96 $4,626.26 -0.42% $4,362.16 $4,697.29 -1.51%
Average Rx/Member/Year 15.84 15.66 -1.13% 13.99 13.89 12.80%Average Days Supply/Rx 26.52 26.48 -0.14% 26.23 26.25 0.86%Copay as Percent of Total Pharmacy 11.46% 10.91% -4.81% 12.41% 11.64% -6.28%Average Generic Copay/Rx $6.53 $6.35 -2.71% $6.12 $5.89 7.89%Average Brand Copay/Rx $30.63 $32.11 4.83% $31.16 $32.63 -1.62%% Generic Use 89.11% 89.96% 0.95% 88.65% 89.43% 0.59%% Non-Formulary 2.56% 2.34% -8.71% 3.56% 3.24% -27.78%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Aggregate
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners178_Ex_Pharmacy_TrendReport Id: 43735
Page 22 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic Class
Current Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
PMPMTrend
MS Agents 23.17% $1,324,418 $14.53 $5,383.81 0.03 11.75% $6.34 $5,291.19 0.01 129.27% 18.13%Chronic Inflammatory Disease 70.31% $1,079,502 $11.85 $1,169.56 0.12 70.84% $11.10 $1,206.14 0.11 6.70% 51.34%Diabetes 64.36% $968,679 $10.63 $144.41 0.88 59.68% $8.90 $153.45 0.70 19.44% 7.48%Stimulants 87.33% $583,303 $6.40 $189.51 0.41 83.72% $4.95 $173.78 0.34 29.28% 5.79%Antivirals 64.94% $541,942 $5.95 $452.37 0.16 80.28% $2.50 $242.62 0.12 138.23% 21.18%Oncology 93.71% $453,205 $4.97 $950.12 0.06 89.76% $5.29 $1,064.58 0.06 -6.03% 19.18%OTHER 92.84% $448,833 $4.93 $62.02 0.95 92.09% $3.55 $52.51 0.81 38.58% 3.35%Asthma 32.13% $420,623 $4.62 $99.44 0.56 32.41% $4.28 $104.52 0.49 7.74% -3.95%Dermatology 94.00% $327,035 $3.59 $111.46 0.39 92.38% $3.36 $117.83 0.34 6.83% -3.75%Anticonvulsants 92.15% $178,201 $1.96 $48.57 0.48 91.51% $1.65 $54.06 0.37 18.43% -10.09%Antidepressants 98.08% $144,744 $1.59 $10.37 1.84 98.19% $1.83 $12.81 1.71 -13.11% -30.87%Contraceptives 94.61% $141,653 $1.55 $27.94 0.67 93.40% $1.92 $28.06 0.82 -18.93% -7.19%Pulmonary Hypertension 87.50% $141,426 $1.55 $736.59 0.03 95.96% $0.46 $284.94 0.02 238.63% 118.31%Inflammatory Bowel 4.71% $137,895 $1.51 $811.15 0.02 9.82% $1.19 $699.92 0.02 26.87% 19.84%Cholesterol 94.72% $132,999 $1.46 $15.02 1.17 94.48% $1.51 $17.08 1.06 -3.22% -26.63%Ophthalmics 69.48% $116,994 $1.28 $72.71 0.21 71.27% $1.24 $65.15 0.23 3.83% -9.22%Antipsychotics 91.98% $116,694 $1.28 $111.35 0.14 90.02% $1.19 $145.01 0.10 7.43% -52.06%Ulcer/GERD 97.47% $113,975 $1.25 $21.67 0.69 96.82% $0.61 $13.31 0.55 105.41% 30.21%Hepatitis 71.88% $112,486 $1.23 $3,515.20 0.00 56.65% $1.63 $11,651.46 0.00 -24.44% -77.14%Narcotic Analgesics 95.64% $112,282 $1.23 $32.40 0.46 95.28% $0.85 $28.32 0.36 45.35% -9.56%HRT 63.09% $103,900 $1.14 $58.73 0.23 59.02% $1.09 $62.56 0.21 4.55% -10.94%Antibiotics 99.71% $94,865 $1.04 $16.42 0.76 99.64% $0.97 $15.28 0.76 7.81% -20.61%Anticoagulants 76.02% $94,608 $1.04 $113.44 0.11 77.65% $0.94 $95.72 0.12 9.93% 22.35%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic ClassCurrent Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
PMPMTrend
Hypertension/Cardiac 99.70% $84,162 $0.92 $3.81 2.91 99.28% $1.00 $4.86 2.46 -7.23% -14.81%Osteoporosis 91.24% $73,038 $0.80 $164.13 0.06 96.99% $0.24 $61.22 0.05 240.83% 15.94%Migraines 89.88% $68,958 $0.76 $95.64 0.09 91.94% $0.64 $81.90 0.09 17.45% -17.39%Androgens 55.25% $67,999 $0.75 $375.68 0.02 55.93% $0.49 $315.57 0.02 52.85% 10.29%Cystic Fibrosis 0.00% $66,631 $0.73 $1,448.50 0.01 6.07% $1.49 $3,663.44 0.00 -50.86% 17.74%Smoking Cessation 53.82% $56,391 $0.62 $165.86 0.04 48.35% $0.35 $181.61 0.02 76.52% 29.17%Erectile Dysfunction 0.00% $54,639 $0.60 $260.19 0.03 0.00% $0.51 $163.02 0.04 16.58% 1.69%Over Active Bladder 86.68% $45,295 $0.50 $92.82 0.06 80.04% $0.43 $104.98 0.05 16.19% -19.35%Immunosuppressants 91.34% $37,028 $0.41 $133.68 0.04 86.84% $0.52 $166.51 0.04 -21.98% -8.89%Antiplatelets 82.06% $27,937 $0.31 $66.83 0.06 87.10% $0.18 $44.84 0.05 66.43% 3.33%Colony Stimulating Factors 0.00% $26,581 $0.29 $4,430.17 0.00 0.00% $0.26 $3,328.81 0.00 10.32% 61.11%Growth Hormones 0.00% $25,815 $0.28 $1,843.92 0.00 0.00% $0.99 $3,006.40 0.00 -71.42% 33.33%Allergy 97.97% $25,447 $0.28 $9.06 0.37 96.70% $0.30 $11.32 0.32 -6.70% -56.25%NSAIDS/COX-2 98.77% $24,281 $0.27 $15.67 0.20 99.66% $0.19 $13.52 0.17 41.61% -28.95%Infertility 40.63% $18,386 $0.20 $287.28 0.01 38.96% $0.37 $422.80 0.01 -44.93% -23.08%Antifungals 98.51% $17,646 $0.19 $32.80 0.07 99.66% $0.10 $21.55 0.06 87.27% -13.64%Thyroid 90.88% $17,237 $0.19 $3.47 0.65 87.87% $0.32 $6.09 0.62 -40.08% -5.00%Biliary Cirrhosis 100.00% $13,224 $0.15 $330.61 0.01 100.00% $0.08 $283.89 0.00 90.91% -40.00%Hypnotics 98.67% $12,152 $0.13 $11.53 0.14 97.80% $0.16 $17.62 0.11 -17.82% 0.00%Corticosteroids 99.11% $10,329 $0.11 $7.69 0.18 99.36% $0.26 $18.58 0.17 -57.18% -69.44%Parkinsons Disease 99.02% $8,108 $0.09 $19.83 0.05 97.08% $0.16 $35.22 0.05 -44.50% -40.00%Antianxiety 99.82% $5,964 $0.07 $2.75 0.29 99.73% $0.08 $4.45 0.23 -22.06% 0.00%Alzheimers Disease 100.00% $4,425 $0.05 $83.50 0.01 95.79% $0.04 $33.46 0.01 31.89% -16.67%
Total 179.07% $8,681,936 $95.27 $72.98 1.31 178.08% $76.51 $66.12 13.89 24.51% 2.06%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic Class
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
SPECIALTY 14.61% $3,389,709 $37.20 $4,586.89 0.10 7.83% $28.02 $4,576.01 0.07 32.74% 16.80%
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 25 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Pharmacy Utilization by Therapeutic Class
Prior Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
MS Agents 14.03% $1,120,506 $12.30 $5,070.16 0.029 5.01% $5.74 $4,962.49 0.014 114.21%Diabetes 64.71% $900,857 $9.89 $136.80 0.867 60.83% $7.95 $140.14 0.681 24.36%Chronic Inflammatory Disease 74.08% $712,897 $7.83 $901.26 0.104 0.00% $0.00 $0.00 0.000 0.00%Stimulants 82.70% $550,858 $6.05 $188.01 0.386 82.50% $4.79 $179.59 0.320 26.32%Hepatitis 52.73% $490,163 $5.38 $8,912.06 0.007 49.66% $2.05 $11,284.80 0.002 162.06%Antivirals 71.11% $447,647 $4.91 $374.91 0.157 75.64% $2.18 $206.30 0.127 124.93%Asthma 28.17% $438,390 $4.81 $102.81 0.562 32.18% $4.14 $99.85 0.498 16.12%OTHER 92.66% $434,571 $4.77 $59.85 0.957 89.47% $3.72 $72.90 0.612 28.23%Oncology 90.45% $380,173 $4.17 $955.21 0.052 93.10% $5.22 $651.21 0.096 -20.03%Dermatology 93.09% $339,952 $3.73 $115.79 0.387 91.24% $3.11 $116.30 0.320 20.18%Antipsychotics 84.83% $243,483 $2.67 $225.24 0.142 79.44% $1.92 $239.60 0.096 39.55%Antidepressants 97.82% $209,826 $2.30 $15.05 1.837 98.19% $2.27 $16.49 1.653 1.39%Anticonvulsants 90.76% $198,761 $2.18 $55.17 0.475 90.74% $1.66 $55.21 0.361 31.30%Cholesterol 92.22% $181,114 $1.99 $19.30 1.236 93.18% $1.74 $18.81 1.111 14.20%Contraceptives 92.84% $152,280 $1.67 $31.13 0.644 92.68% $2.00 $30.10 0.799 -16.56%Ophthalmics 63.55% $128,199 $1.41 $77.89 0.217 66.88% $1.21 $66.35 0.219 15.99%Narcotic Analgesics 95.87% $123,660 $1.36 $31.76 0.513 94.90% $1.06 $31.33 0.405 28.35%Antibiotics 99.49% $119,050 $1.31 $20.09 0.781 99.57% $1.36 $21.06 0.778 -4.24%HRT 62.58% $116,393 $1.28 $60.00 0.256 54.31% $1.01 $57.75 0.210 26.20%Inflammatory Bowel 4.12% $115,103 $1.26 $677.08 0.022 28.56% $1.47 $609.23 0.029 -14.06%Hypertension/Cardiac 99.46% $97,942 $1.08 $4.45 2.901 99.14% $1.10 $5.28 2.506 -2.57%Ulcer/GERD 96.58% $87,009 $0.96 $15.81 0.725 95.92% $0.61 $13.30 0.552 56.16%Migraines 88.75% $83,873 $0.92 $94.35 0.117 91.71% $0.66 $80.92 0.098 39.90%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Pharmacy Utilization by Therapeutic ClassPrior Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
Anticoagulants 79.97% $77,757 $0.85 $109.67 0.093 83.73% $0.77 $83.21 0.111 10.42%Pulmonary Hypertension 33.33% $64,855 $0.71 $3,603.06 0.002 52.33% $0.22 $2,095.31 0.001 217.03%Osteoporosis 89.08% $63,279 $0.69 $157.02 0.053 95.21% $0.22 $49.02 0.054 212.72%Androgens 54.34% $62,282 $0.68 $360.01 0.023 49.44% $0.52 $334.12 0.019 32.41%Allergy 93.48% $57,938 $0.64 $19.57 0.390 90.97% $0.59 $20.74 0.340 8.38%Cystic Fibrosis 0.00% $56,881 $0.62 $1,458.48 0.005 1.50% $0.73 $2,193.77 0.004 -14.46%Over Active Bladder 82.92% $56,142 $0.62 $116.96 0.063 77.99% $0.47 $109.44 0.052 30.28%Erectile Dysfunction 0.00% $53,620 $0.59 $200.08 0.035 0.00% $0.71 $129.09 0.066 -17.42%Smoking Cessation 48.38% $43,739 $0.48 $157.90 0.036 48.79% $0.30 $160.89 0.022 60.50%Immunosuppressants 88.81% $41,131 $0.45 $143.81 0.038 85.36% $0.59 $181.66 0.039 -22.86%NSAIDS/COX-2 99.03% $34,665 $0.38 $21.05 0.217 97.62% $0.33 $22.80 0.175 14.40%Corticosteroids 98.62% $32,659 $0.36 $23.68 0.182 99.35% $0.32 $22.19 0.172 12.42%Antiplatelets 80.91% $27,372 $0.30 $62.21 0.058 88.71% $0.15 $35.64 0.051 99.51%Infertility 41.67% $23,546 $0.26 $245.27 0.013 43.61% $0.21 $276.03 0.009 20.70%Biliary Cirrhosis 100.00% $22,838 $0.25 $340.87 0.009 94.97% $0.12 $15.48 0.095 105.50%Antifungals 100.00% $19,936 $0.22 $32.21 0.082 99.49% $0.16 $33.54 0.057 37.92%Growth Hormones 0.00% $19,319 $0.21 $1,609.93 0.002 0.00% $0.70 $3,034.76 0.003 -69.77%Thyroid 91.34% $18,617 $0.20 $3.63 0.675 87.95% $0.34 $6.46 0.628 -39.54%Colony Stimulating Factors 0.00% $16,477 $0.18 $5,492.38 0.000 0.00% $0.36 $3,774.57 0.001 -49.07%Parkinsons Disease 97.36% $14,052 $0.15 $30.95 0.060 97.29% $0.16 $33.09 0.057 -1.22%Hypnotics 99.47% $12,210 $0.13 $10.76 0.150 97.68% $0.19 $19.18 0.120 -29.91%Antianxiety 100.00% $6,113 $0.07 $2.90 0.278 99.68% $0.10 $5.56 0.222 -34.80%Alzheimers Disease 72.22% $5,284 $0.06 $146.78 0.005 74.65% $0.08 $71.23 0.013 -24.72%
Total 179.07% $8,503,421 $93.35 $70.70 15.843 178.08% $65.34 $56.82 13.798 42.87%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 27 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Pharmacy Utilization by Therapeutic Class
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
SPECIALTY 9.74% $2,901,118 $31.85 $4,483.95 0.085 6.47% $24.03 $4,179.19 0.069 32.51%
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 28 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 10 Pharmacy PMPM by Therapeutic Class
All Packages/All Sites YTD Qtrly
C P Prior YearCurrent Year C Current Aggregate P Prior Aggregate
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 29 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Channel Management
All Packages/All Sites YTD Qtrly
Utilization and Trend Aggregate
Percent Total Rx Prior Year Current Year % Change Prior Year Current YearCurrent Year
Variance
% Retail 42.50% 41.30% -2.82% 43.66% 42.62% -3.10%
% Extended Retail, 3-month Rx 55.05% 56.45% 2.53% 54.57% 55.73% 1.28%
% Mail Order 1.91% 1.63% -14.53% 1.28% 1.12% 46.10%
% Specialty 0.54% 0.62% 15.47% 0.49% 0.53% 17.40%
Utilization and Trend
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735179_Ex_Pharmacy_by_Class
Page 30 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Channel Management
Prior Year Actual Aggregate
Chain Name % Total Rx Total Rx % Paid Paid % Total Rx % PaidVariance in
% PaidCVS PHARMACARE SPECIALTY PHARM 0.45% 547 30.75% $2,614,432 0.40% 27.77% 10.71%
WALGREENS 33.56% 40,359 23.33% $1,983,595 29.76% 22.41% 4.11%
HEALTHPARTNERS MAILORDER 13.35% 16,061 9.33% $793,262 9.47% 7.56% 23.47%
HEALTHPARTNERS 9.55% 11,490 7.16% $609,235 5.58% 4.47% 60.45%
TARGET 13.64% 16,408 7.15% $607,588 14.25% 8.20% -12.88%
Total 70.56% 84,865 77.71% $6,608,111 59.46% 70.40% 10.38%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Current Year Actual Aggregate
Chain Name % Total Rx Total Rx % Paid Paid % Total Rx % PaidVariance in
% PaidPaid
TrendCVS PHARMACARE SPECIALTY PHARM 0.53% 627 34.08% $2,958,925 0.40% 29.05% 17.32% 10.83%
WALGREENS 33.78% 40,187 21.91% $1,902,409 30.60% 21.11% 3.78% -6.09%
HEALTHPARTNERS MAILORDER 12.56% 14,941 8.48% $736,383 8.88% 6.88% 23.25% -9.11%
HEALTHPARTNERS 9.25% 11,003 7.02% $609,400 5.42% 4.57% 53.58% -1.96%
TARGET 12.85% 15,285 5.90% $512,293 13.65% 7.90% -25.28% -17.48%
Total 68.97% 82,043 77.40% $6,719,410 58.95% 69.51% 10.86% -23.81%
Top 5 Pharmacy Chains
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735179_Ex_Pharmacy_by_Class
Page 31 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Top 20 Drugs by Cost
Drug Therapeutic Brand / Rx Claims Paid / RxName Class Generic Prior Current %Change Prior Current %Change Prior Current %ChangeHumira* Chronic Inflammatory DisBrand 124 140 12.90% $422,691 $602,565 42.55% $3,408.80 $4,304.03 26.26%Humalog Diabetes Brand 680 669 -1.62% $298,198 $323,298 8.42% $438.53 $483.26 10.20%Enbrel* Chronic Inflammatory DisBrand 48 80 66.67% $164,130 $308,477 87.95% $3,419.37 $3,855.97 12.77%Rebif* MS Agents Brand 42 50 19.05% $229,948 $305,781 32.98% $5,474.95 $6,115.62 11.70%Adderall Stimulants Generic 861 964 11.96% $227,464 $259,259 13.98% $264.19 $268.94 1.80%Lantus Diabetes Brand 827 836 1.09% $246,668 $232,207 -5.86% $298.27 $277.76 -6.88%Copaxone* MS Agents Brand 54 40 -25.93% $302,568 $230,625 -23.78% $5,603.11 $5,765.62 2.90%Glatopa* MS Agents Generic 31 57 83.87% $122,330 $223,093 82.37% $3,946.14 $3,913.91 -0.82%Gilenya* MS Agents Brand 33 33 0.00% $184,270 $220,534 19.68% $5,583.93 $6,682.85 19.68%Advair Asthma Brand 709 580 -18.19% $209,094 $193,638 -7.39% $294.91 $333.86 13.21%Tecfidera* MS Agents Brand 24 26 8.33% $132,318 $160,290 21.14% $5,513.24 $6,165.02 11.82%Imatinib* Oncology Generic 5 or Under 22 0.00% $0 $155,575 0.00% $0.00 $7,071.60 0.00%Victoza Diabetes Brand 189 249 31.75% $102,104 $148,653 45.59% $540.23 $597.00 10.51%Methylphenidate Stimulants Generic 793 843 6.31% $121,042 $139,735 15.44% $152.64 $165.76 8.60%Xyrem* OTHER Brand 13 12 -7.69% $120,084 $121,218 0.94% $9,237.23 $10,101.51 9.36%Truvada Antivirals Brand 5 or Under 83 0.00% $0 $119,500 0.00% $0.00 $1,439.76 0.00%Atripla Antivirals Brand 42 47 11.90% $94,453 $114,640 21.37% $2,248.88 $2,439.15 8.46%Letairis* Pulmonary Hypertension Brand 5 or Under 12 0.00% $0 $104,155 0.00% $0.00 $8,679.57 0.00%Aubagio* MS Agents Brand 5 or Under 17 0.00% $0 $98,981 0.00% $0.00 $5,822.41 0.00%Ibrance* Oncology Brand 5 or Under 11 0.00% $0 $94,364 0.00% $0.00 $8,578.52 0.00%
Total 4,470 4,771 6.73% $2,977,362 $4,156,588 39.61% $666.08 $871.22 30.80%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR* Specialty Drug
Report Period: 2/1/2017 12:Run Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735180_Ex_Pharmacy_Top_20
Page 32 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Top 20 Drugs by Volume
Drug Therapeutic Brand / Rx Claims Paid / RxName Class Generic Prior Current %Change Prior Current %Change Prior Current %ChangeLevothyroxine Thyroid Generic 4,636 4,452 -3.97% $13,835 $12,815 -7.37% $2.98 $2.88 -3.36%Atorvastatin Cholesterol Generic 4,238 4,333 2.24% $7,248 $1,926 -73.43% $1.71 $0.44 -74.27%Lisinopril Hypertension/Cardiac Generic 4,303 4,251 -1.21% $902 $501 -44.44% $0.21 $0.12 -42.86%Omeprazole Ulcer/GERD Generic 3,514 3,165 -9.93% $2,584 $1,137 -56.00% $0.74 $0.36 -51.35%Metformin Diabetes Generic 2,887 2,998 3.84% $2,296 $1,966 -14.39% $0.80 $0.66 -17.50%Simvastatin Cholesterol Generic 3,004 2,576 -14.25% $572 $239 -58.15% $0.19 $0.09 -52.63%Amlodipine Hypertension/Cardiac Generic 2,390 2,575 7.74% $331 $254 -23.30% $0.14 $0.10 -28.57%Sertraline Antidepressants Generic 2,311 2,344 1.43% $1,863 $687 -63.09% $0.81 $0.29 -64.20%Hydrochlorothiazide Hypertension/Cardiac Generic 2,603 2,335 -10.30% $362 $170 -52.98% $0.14 $0.07 -50.00%Metoprolol Hypertension/Cardiac Generic 2,345 2,301 -1.88% $15,251 $9,417 -38.25% $6.50 $4.09 -37.08%Bupropion Antidepressants Generic 1,911 1,951 2.09% $45,954 $20,562 -55.25% $24.05 $10.54 -56.17%Fluticasone Allergy Generic 1,885 1,849 -1.91% $5,300 $1,785 -66.33% $2.81 $0.97 -65.48%Atenolol Hypertension/Cardiac Generic 1,908 1,810 -5.14% $216 $205 -4.79% $0.11 $0.11 0.00%Fluoxetine Antidepressants Generic 1,865 1,760 -5.63% $9,882 $1,524 -84.58% $5.30 $0.87 -83.58%Citalopram Antidepressants Generic 1,639 1,728 5.43% $272 $204 -24.88% $0.17 $0.12 -29.41%Trazodone Antidepressants Generic 1,730 1,543 -10.81% $1,275 $1,111 -12.86% $0.74 $0.72 -2.70%Losartan Hypertension/Cardiac Generic 1,365 1,538 12.67% $648 $421 -35.00% $0.47 $0.27 -42.55%Lisinopril-Hctz Hypertension/Cardiac Generic 1,458 1,372 -5.90% $245 $146 -40.36% $0.17 $0.11 -35.29%Ventolin Asthma Brand 1,372 1,342 -2.19% $25,190 $33,425 32.69% $18.36 $24.91 35.68%Gabapentin Anticonvulsants Generic 5 or Under 1,313 0.00% $0 $4,915 0.00% $0.00 $3.74 0.00%
Total 47,364 47,536 0.36% $134,224 $93,412 -30.41% $2.83 $1.97 -30.66%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Report Period: 2/1/2017 12:Run Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735180_Ex_Pharmacy_Top_20
Page 33 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Tier Utilization
Utilization Category Tier 1 Tier 2 Tier 3 Out of Network Total
Professional 17,171,776.47 3,923,909.71 0 189,071.57 $21,284,758
Hospital IP 3,975,670.28 5,101,403.86 0 90,154.95 $9,167,229
Hospital OP 6,419,771.21 3,894,143.78 0 248,430.13 $10,562,345
Pharmacy 9,298,655.22 0 0 0 $9,298,655
DME, Transportation, Other 995,947.46 128,875.77 0 10,525.8 $1,135,349
Preventive/Accidental Dental 0 0 0 0 $0
Total 37,861,820.64 13,048,333.12 0 538,182.46 $51,448,336
Percent of Claims 73.59% 25.36% 0.00% 1.05% 100.00%
Members 7,437 2,634 0 223 10,294
Percent Members 72.25% 25.59% 0.00% 2.17% 100.00%
All Packages/All Sites YTD Qtrly
Notes: Members will be counted more than once if they incurred services in multiple networks.Members with only out-of-network claims = 0Claims include IBNRSome benefit plans do not utilize all tier levles. In these cases, there would be no claims dollars.
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
190_Ex_Tier_Network_UtilizationReport Id: 43735
Page 34 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Tier Utilization
Utilization Category Tier 1 Tier 2 Tier 3 Out of Network Total
Professional 15,097,247.83 3,655,457.32 0 211,168.9 $18,963,874
Hospital IP 3,709,688.29 3,896,223.06 0 270,202.52 $7,876,114
Hospital OP 5,768,018.17 3,970,657.73 0 678,526.63 $10,417,203
Pharmacy 7,381,759.73 1,637,393.48 0 0 $9,019,153
DME, Transportation, Other 831,381.43 129,533.01 0 16,218.6 $977,133
Preventive/Accidental Dental 0 0 0 0 $0
Total 32,788,095.44 13,289,264.6 0 1,176,116.65 $47,253,477
Percent of Claims 69.39% 28.12% 0.00% 2.49% 100.00%
Members 7,364 4,930 0 227 12,521
Percent Members 58.81% 39.37% 0.00% 1.81% 100.00%
All Packages/All Sites YTD Qtrly
Notes: Members will be counted more than once if they incurred services in multiple networks.Members with only out-of-network claims = 0Claims include IBNRSome benefit plans do not utilize all tier levels. In these cases, there would be no claims dollars.
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
190_Ex_Tier_Network_UtilizationReport Id: 43735
Page 35 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Monthly Summary - Contracts
All Packages/All Sites YTD Qtrly
Member and contract counts are as of the 15th of each month and include retroactive adjustments.
Period Members Total Single Family
Jan 2016 7,572 3,740 2,273 1,467
Feb 2016 7,559 3,737 2,272 1,465
Mar 2016 7,595 3,749 2,276 1,473
Apr 2016 7,610 3,767 2,295 1,472
May 2016 7,595 3,762 2,297 1,465
Jun 2016 7,626 3,768 2,297 1,471
Jul 2016 7,576 3,750 2,289 1,461
Aug 2016 7,581 3,758 2,300 1,458
Sep 2016 7,590 3,760 2,300 1,460
Oct 2016 7,616 3,751 2,281 1,470
Nov 2016 7,611 3,754 2,290 1,464
Dec 2016 7,601 3,742 2,276 1,466
Total 91,132 45,038 27,446 17,592
Average 7,594 3,753 2,287 1,466
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 36 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Monthly Summary - Contracts
All Packages/All Sites YTD Qtrly
Member and contract counts are as of the 15th of each month and include retroactive adjustments.
Period Members Total Single Family
Jan 2015 7,612 3,776 2,293 1,483
Feb 2015 7,593 3,770 2,292 1,478
Mar 2015 7,589 3,771 2,298 1,473
Apr 2015 7,623 3,790 2,314 1,476
May 2015 7,609 3,782 2,310 1,472
Jun 2015 7,593 3,769 2,298 1,471
Jul 2015 7,588 3,754 2,284 1,470
Aug 2015 7,622 3,751 2,274 1,477
Sep 2015 7,577 3,737 2,268 1,469
Oct 2015 7,557 3,732 2,268 1,464
Nov 2015 7,564 3,736 2,271 1,465
Dec 2015 7,566 3,732 2,263 1,469
Total 91,093 45,100 27,433 17,667
Average 7,591 3,758 2,286 1,472
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 37 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Monthly Summary - Revenue and Claims
All Packages/All Sites YTD Qtrly
Revenue is shown on an earned premium basis and includes retroactive adjustments. Revenue only includes medical premiums;special charges are not included.
Period Members Total PMPM Total PMPM Care Ratio
Jan 2016 7,572 $4,488,443 $592.77 $3,541,703 $467.74
Feb 2016 7,559 $4,481,907 $592.92 $4,239,044 $560.79
Mar 2016 7,595 $4,496,974 $592.10 $4,380,492 $576.76
Apr 2016 7,610 $4,510,417 $592.70 $4,573,015 $600.92
May 2016 7,595 $4,500,083 $592.51 $5,201,060 $684.80
Jun 2016 7,626 $4,512,336 $591.70 $4,369,435 $572.97
Jul 2016 7,576 $4,486,043 $592.14 $4,531,363 $598.12
Aug 2016 7,581 $4,490,452 $592.33 $4,468,789 $589.47
Sep 2016 7,590 $4,494,219 $592.12 $4,223,935 $556.51
Oct 2016 7,616 $4,498,828 $590.71 $4,081,577 $535.92
Nov 2016 7,611 $4,492,269 $590.23 $4,264,854 $560.35
Dec 2016 7,601 $4,485,762 $590.15 $5,690,375 $748.64
Total 91,132 $53,937,731 $53,565,640 99.31%
Average 7,594 $4,494,811 $591.87 $4,463,803 $587.78
Claims include IBNR and pooling charges
Revenue ClaimsCurrent Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 38 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Monthly Summary - Revenue and Claims
All Packages/All Sites YTD Qtrly
Revenue is shown on an earned premium basis and includes retroactive adjustments. Revenue only includes medical premiums;special charges are not included.
Period Members Total PMPM Total PMPM Care Ratio
Jan 2015 7,612 $4,382,113 $575.68 $3,797,656 $498.90
Feb 2015 7,593 $4,373,323 $575.97 $3,412,764 $449.46
Mar 2015 7,589 $4,370,339 $575.88 $4,066,332 $535.82
Apr 2015 7,623 $4,384,641 $575.19 $4,412,285 $578.81
May 2015 7,609 $4,376,122 $575.12 $3,747,879 $492.56
Jun 2015 7,593 $4,364,128 $574.76 $4,445,837 $585.52
Jul 2015 7,588 $4,352,489 $573.60 $4,076,387 $537.21
Aug 2015 7,622 $4,356,819 $571.61 $3,872,488 $508.07
Sep 2015 7,577 $4,337,716 $572.48 $4,468,647 $589.76
Oct 2015 7,557 $4,328,635 $572.80 $3,925,901 $519.51
Nov 2015 7,564 $4,334,346 $573.02 $4,257,483 $562.86
Dec 2015 7,566 $4,335,515 $573.03 $4,295,997 $567.80
Total 91,093 $52,296,184 $48,779,655 93.28%
Average 7,591 $4,358,015 $574.10 $4,064,971 $535.49
Claims include IBNR and pooling charges
Revenue ClaimsPrior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 39 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Contract Distribution
All Packages/All Sites YTD Qtrly
C PCurrent Year Prior Year
Average Members per Ramsey County [12900] Prior Year Aggregate
All Family Type Contracts: 3.62 3.60 3.42
All Contracts: 2.02 2.02 2.04
C Current Aggregate P Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners Report Id: 43735
200_Ex_Monthly_Summary
Page 40 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Demographics Summary
Member Months Average % of Total Aggregate % of Total
Female 50,376 4,198 55.28% 53.54%
Male 40,756 3,396 44.72% 46.46%
Total 91,132 7,594 100.00% 100.00%
All Packages/All Sites YTD Qtrly
Current Year Gender Distribution
Current Year Relationship Distribution
Member Months Average % of Total Aggregate % of Total
Policyholder 44,627 3,719 48.97% 48.81%
Dependent 46,505 3,875 51.03% 51.19%
Total 91,132 7,594 100.00% 100.00%
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
210_Ex_Demographics_SummaryReport Id: 43735
Page 41 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Demographics Summary
Member Months Average % of Total Aggregate % of Total
Female 50,378 4,198 55.30% 53.55%
Male 40,715 3,393 44.70% 46.45%
Total 91,093 7,591 100.00% 100.00%
All Packages/All Sites YTD Qtrly
Prior Year Gender Distribution
Prior Year Relationship Distribution
Member Months Average % of Total Aggregate % of Total
Policyholder 44,884 3,740 49.27% 49.20%
Dependent 46,209 3,851 50.73% 50.80%
Total 91,093 7,591 100.00% 100.00%
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
210_Ex_Demographics_SummaryReport Id: 43735
Page 42 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Demographics: Detail
Age RangeFemale
Policyholder DependentMale
Policyholder Dependent Total % of Total
Under 1 0 24 0 42 66 0.87%
1 - 4 0 131 0 172 303 3.99%
5 - 9 0 264 0 228 492 6.47%
10 - 14 0 251 1 267 519 6.83%
15 - 19 2 310 0 307 619 8.14%
20 - 24 9 296 12 267 584 7.68%
25 - 29 100 78 65 51 294 3.87%
30 - 34 195 58 146 36 435 5.72%
35 - 39 261 85 138 85 569 7.49%
40 - 44 226 94 153 88 561 7.38%
45 - 49 268 89 186 77 620 8.16%
50 - 54 319 96 234 89 738 9.71%
55 - 59 369 94 230 103 796 10.47%
60 - 64 423 64 246 107 840 11.05%
65 Over 74 11 46 34 165 2.17%
Total 2,246 1,945 1,457 1,953 7,601 100.00%
All Packages/All Sites YTD Qtrly
Counts shown are for the last month in the reporting period.
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
220_Ex_Demographics_DetailReport Id: 43735
Page 43 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Demographics: Detail
Age RangeFemale
Policyholder DependentMale
Policyholder Dependent Total % of Total
Under 1 0 28 0 36 64 0.85%
1 - 4 0 144 0 163 307 4.06%
5 - 9 0 246 1 236 483 6.38%
10 - 14 0 268 0 254 522 6.90%
15 - 19 2 308 0 307 617 8.15%
20 - 24 11 288 13 271 583 7.71%
25 - 29 97 61 64 60 282 3.73%
30 - 34 185 63 126 36 410 5.42%
35 - 39 260 71 143 79 553 7.31%
40 - 44 227 99 148 75 549 7.26%
45 - 49 260 81 184 89 614 8.12%
50 - 54 321 106 229 86 742 9.81%
55 - 59 409 90 226 108 833 11.01%
60 - 64 409 66 276 99 850 11.23%
65 Over 69 10 45 33 157 2.08%
Total 2,250 1,929 1,455 1,932 7,566 100.00%
All Packages/All Sites YTD Qtrly
Counts shown are for the last month in the reporting period.
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
220_Ex_Demographics_DetailReport Id: 43735
Page 44 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Age Distribution
All Packages/All Sites YTD Qtrly
CG Current Year CA Current Aggregate PG Prior Year PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
220_Ex_Demographics_DeReport Id: 43735
Page 45 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Cost Savings Detail
All Packages/All Sites YTD Qtrly
COB Savings
COB SavingsWorkers Compensation $8,293 $0 $0 $0 $1,364 $0 $9,657No-Fault $922 $0 $6,829 $0 $4,058 $0 $11,809Third Party Liability $0 $0 $0 $0 $0 $0 $0Occupational Health $0 $0 $0 $0 $0 $0 $0Other Insurance: Under 65 $430,705 $542,048 $1,067,327 $0 $25,581 $0 $2,065,662Other Insurance: Over 65 $186,050 $968 $648,993 $0 $10,546 $0 $846,558Total: $625,970 $543,017 $1,723,149 $0 $41,549 $0 $2,933,685
Benefit Design Savings
Benefit Design SavingsDeductibles $223,487 $2,391 $13,868 $0 $10,087 $0 $249,833Copayments/Coinsurance $1,208,578 $82,178 $397,730 $1,063,489 $185,626 $0 $2,937,600Other Member Liability $716 $71 $32,534 $0 $0 $0 $33,322Total: $1,432,781 $84,641 $444,132 $1,063,489 $195,713 $0 $3,220,755
Other Savings
Other SavingsUCR Limits $34,562 $0 $0 $0 $0 $0 $34,562Ineligible Services $42,501 $145 -$18,816 $0 $35,340 $0 $59,170Total: $77,063 $145 -$18,816 $0 $35,340 $0 $93,733
Provider Discount Savings
Provider Discount SavingsNegotiated Discounts $11,769,785 $7,797,704 $13,733,460 $9,335,989 $725,033 $0 $43,361,972Total: $11,769,785 $7,797,704 $13,733,460 $9,335,989 $725,033 $0 $43,361,972
Professional Hospital IP Hospital OP Pharmacy Other Dental TotalBilled Charge $33,460,569 $16,793,596 $25,612,509 $18,972,423 $2,046,691 $0 $96,885,787
Grand Total Savings $13,905,600 $8,425,507 $15,881,925 $10,399,478 $997,635 $0 $49,610,145
Claims$19,894,723 $8,506,323 $9,873,188 $8,681,936 $1,056,178 $0 $48,012,348
(billed charge - grand total savings + tax)
Provider Tax $339,754 $138,235 $142,605 $108,991 $7,122 $0 $736,706
Savings Percentage 41.56% 50.17% 62.01% 54.81% 48.74% 0.00% 51.20%(based on billed charge)
Note: Claims do not include IBNR
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
310_Ex_Cost_Savings_DetailReport Id: 43735
Page 46 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Cost Savings Detail
All Packages/All Sites YTD Qtrly
COB Savings
COB SavingsWorkers Compensation $158 $0 $15,746 $0 $0 $0 $15,904No-Fault $2,406 $0 $270 $0 $0 $0 $2,676Third Party Liability $21 $0 $0 $0 $0 $0 $21Occupational Health $0 $0 $0 $0 $0 $0 $0Other Insurance: Under 65 $456,521 $819,573 $1,025,491 $0 $23,590 $0 $2,325,176Other Insurance: Over 65 $116,808 $19,184 $59,893 $0 $332 $0 $196,216Total: $575,913 $838,757 $1,101,400 $0 $23,922 $0 $2,539,992
Benefit Design Savings
Benefit Design SavingsDeductibles $226,484 $6,297 $15,502 $0 $6,843 $0 $255,126Copayments/Coinsurance $1,128,354 $94,559 $380,720 $1,101,034 $153,456 $0 $2,858,123Other Member Liability $52 $1,755 $4,133 $0 $0 $0 $5,941Total: $1,354,890 $102,611 $400,355 $1,101,034 $160,299 $0 $3,119,190
Other Savings
Other SavingsUCR Limits $84,675 $0 $0 $0 $0 $0 $84,675Ineligible Services $18,486 $5,514 $21 $0 $67,771 $0 $91,792Total: $103,160 $5,514 $21 $0 $67,771 $0 $176,466
Provider Discount Savings
Provider Discount SavingsNegotiated Discounts $10,605,142 $7,206,487 $12,798,069 $8,109,460 $653,160 $0 $39,372,317Total: $10,605,142 $7,206,487 $12,798,069 $8,109,460 $653,160 $0 $39,372,317
Professional Hospital IP Hospital OP Pharmacy Other Dental TotalBilled Charge $30,247,199 $15,520,822 $23,994,444 $17,598,440 $1,820,307 $0 $89,181,211
Grand Total Savings $12,639,106 $8,153,370 $14,299,844 $9,210,494 $905,151 $0 $45,207,965
Claims$17,909,009 $7,484,934 $9,830,810 $8,503,421 $922,237 $0 $44,650,412
(billed charge - grand total savings + tax)
Provider Tax $300,916 $117,483 $136,210 $115,476 $7,082 $0 $677,166
Savings Percentage 41.79% 52.53% 59.60% 52.34% 49.73% 0.00% 50.69%(based on billed charge)
Note: Claims do not include IBNR
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
310_Ex_Cost_Savings_DetailReport Id: 43735
Page 47 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service Categories
Provider Claims ClaimantsHEALTHPARTNERS MEDICAL GROUP $4,809,334 3,695
REGIONS HOSPITAL-RAD/ACUTE/SLEEP $3,418,292 962
CVS/SPECIALTY # $2,958,925 68
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW WEST $1,659,911 175
UNITED HOSPITAL $1,657,168 242
MAYO CLINIC ROCHESTER $1,275,346 93
HEALTHEAST ST JOHNS & MIDWAY $1,071,439 286
MERCY HOSPITAL $800,492 58
MAYO CLINIC HOSPITAL-ROCHESTER $770,237 34
HEALTHPARTNERS MAIL ORDER PHARMACY $736,383 525
MINNESOTA ONCOLOGY HEMATOLOGY, PA $633,004 55
HEALTHEAST WOODWINDS HOSPITAL $609,700 160
ABBOTT NORTHWESTERN HOSPITAL $597,840 123
FAIRVIEW PHARMACY SERVICES LLC-HH $594,346 5 or under
PARK NICOLLET CLINIC $573,868 383
CVS PHARMACY # $552,701 1,321
HEALTHEAST ST JOSEPHS $505,879 80
PARK NICOLLET METHODIST HOSPITAL-ACUTE $469,638 85
FAIRVIEW SOUTHDALE HOSPITAL $443,343 78
CHILDRENS HEALTH CARE-ST PAUL $439,984 186
HEALTHPARTNERS SAME DAY SURG CENTER $422,767 261
SUMMIT ORTHOPEDICS,LTD $366,680 264
TWIN CITIES ANESTHESIA ASSOCIATES PA $328,409 295
All Packages/All Sites YTD Qtrly
Current Year by Dollars Paid
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 48 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service CategoriesProvider Claims ClaimantsLAKEVIEW HOSPITAL $310,539 90
TWIN CITIES ORTHOPEDICS,PA $309,085 196
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 49 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Top 25 Medical Providers - All Service Categories
Provider Claims ClaimantsHEALTHPARTNERS MEDICAL GROUP $4,680,044 3,636
REGIONS HOSPITAL-RAD/ACUTE/SLEEP $3,392,796 1,016
CVS/SPECIALTY # $2,614,432 67
CHILDRENS HEALTH CARE-ST PAUL $1,194,438 175
MAYO CLINIC ROCHESTER $1,189,028 85
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW WEST $1,072,109 174
UNITED HOSPITAL $991,016 207
HEALTHEAST ST JOHNS & MIDWAY $959,240 223
MAYO CLINIC HOSPITAL-ROCHESTER $827,846 34
HEALTHPARTNERS MAIL ORDER PHARMACY $793,262 553
HEALTHEAST ST JOSEPHS $713,294 97
CVS PHARMACY # $654,085 1,367
HENNEPIN COUNTY MEDICAL CENTER $638,608 52
FAIRVIEW PHARMACY SERVICES LLC-HH $554,000 5 or under
ABBOTT NORTHWESTERN HOSPITAL $475,907 132
HEALTHEAST WOODWINDS HOSPITAL $433,403 175
HEALTHPARTNERS SAME DAY SURG CENTER $398,839 248
SUMMIT ORTHOPEDICS,LTD $386,690 289
PARK NICOLLET CLINIC $382,102 329
ST MARYS HOSP-ROCHESTER/TRANSPLANT $337,025 5 or under
MINNESOTA GASTROENTEROLOGY PA $334,963 193
WALGREENS $313,744 628
CREATIVE CARE,INC $313,613 5 or under
All Packages/All Sites YTD Qtrly
Prior Year by Dollars Paid
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 50 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Top 25 Medical Providers - All Service CategoriesProvider Claims ClaimantsPARK NICOLLET METHODIST HOSPITAL-ACUTE $306,932 57
FAIRVIEW SOUTHDALE HOSPITAL $296,569 63
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 51 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service Categories
Provider Claimants ClaimsHEALTHPARTNERS MEDICAL GROUP 3,695 $4,809,334
REGIONS HOSPITAL-RAD/ACUTE/SLEEP 962 $3,418,292
UNITED HOSPITAL 242 $1,657,168
HEALTHEAST ST JOHNS & MIDWAY 286 $1,071,439
HEALTHPARTNERS MAIL ORDER PHARMACY 525 $736,383
PARK NICOLLET CLINIC 383 $573,868
CVS PHARMACY # 1,321 $552,701
HEALTHPARTNERS SAME DAY SURG CENTER 261 $422,767
SUMMIT ORTHOPEDICS,LTD 264 $366,680
TWIN CITIES ANESTHESIA ASSOCIATES PA 295 $328,409
WALGREENS 628 $302,999
CUB PHARMACY 337 $284,458
ST PAUL RADIOLOGY PA 1,344 $275,485
HEALTHPARTNERS MENTAL HEALTH 282 $257,917
EMERGENCY PHYSICIANS,PA 294 $209,920
CVS PHARMACY 532 $203,898
HEALTHPARTNERS MEDICAL GROUP-NW ALLIANCE 247 $186,703
REGIONS HOSPITAL-PRO FEE 339 $176,086
DERMATOLOGY CONSULTANTS,PA 258 $104,489
ST PAUL EYE CLINIC,PA 272 $80,188
FULCRUM HEALTH,INC 505 $79,446
HOSPITAL PATHOLOGY ASSOCIATES 288 $62,512
HEALTHPARTNERS WORKSITE HEALTH 681 $23,155
All Packages/All Sites YTD Qtrly
Current Year by Claimant Count
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 52 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service CategoriesProvider Claimants ClaimsVIRTUWELL 258 $16,058
NOT APPLICABLE 334 $12,189
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 53 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Top 25 Medical Providers - All Service Categories
Provider Claimants ClaimsHEALTHPARTNERS MEDICAL GROUP 3,636 $4,680,044
ST PAUL RADIOLOGY PA 1,382 $241,320
CVS PHARMACY # 1,367 $654,085
REGIONS HOSPITAL-RAD/ACUTE/SLEEP 1,016 $3,392,796
HEALTHPARTNERS WORKSITE HEALTH 991 $32,979
WALGREENS 628 $313,744
HEALTHPARTNERS MAIL ORDER PHARMACY 553 $793,262
FULCRUM HEALTH,INC 526 $82,582
CVS PHARMACY 479 $211,505
CUB PHARMACY 350 $269,855
REGIONS HOSPITAL-PRO FEE 346 $163,861
PARK NICOLLET CLINIC 329 $382,102
NOT APPLICABLE 291 $10,232
SUMMIT ORTHOPEDICS,LTD 289 $386,690
HEALTHPARTNERS MENTAL HEALTH 285 $263,198
TARGET CLINIC MINNESOTA 283 $14,173
TWIN CITIES ANESTHESIA ASSOCIATES PA 278 $282,008
EMERGENCY PHYSICIANS,PA 263 $147,101
DERMATOLOGY CONSULTANTS,PA 251 $117,998
HEALTHPARTNERS SAME DAY SURG CENTER 248 $398,839
HEALTHPARTNERS ST. PAUL PHARMACY 247 $112,896
ST PAUL EYE CLINIC,PA 241 $66,604
HEALTHPARTNERS WOODBURY PHARMACY 236 $80,488
All Packages/All Sites YTD Qtrly
Prior Year by Claimant Count
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 54 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Top 25 Medical Providers - All Service CategoriesProvider Claimants ClaimsSUBURBAN RADIOLOGIC CONSULTANTS 235 $39,744
VIRTUWELL 233 $13,462
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 55 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Effect of Catastrophic Claims on PMPM
Amount Aggregate Variance PMPM Trend
Total Claims $51,448,336
Total Claims: Per Member Per Month $564.55 $458.40 23.16% 8.83%
Catastrophic Claims Excess Amount $15,470,710 (for members with $25,000 +, the amount over $25,000
Catastrophic Excess Amount: % of Total Claims 30.07% 30.66%
(catastrophic claims as a percentage of total claims)
Net Claims $35,977,626
(total claims less catastrophic excess)
Net Claims: Per Member Per Month $394.79 $317.84 24.21% 7.43%
Note: Catastrophic Dollars do not include IBNR Claims include IBNR
All Packages/All Sites YTD Qtrly
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 A © Copyright 2017 HealthPartners
400_Ex_Effect_Catastrophic_ClaimsReport Id: 43735
Page 56 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Effect of Catastrophic Claims on PMPM
Amount Aggregate Variance
Total Claims $47,253,477
Total Claims: Per Member Per Month $518.74 $435.33 19.16%
Catastrophic Claims Excess Amount $13,777,050 (for members with $25,000 +, the amount over $25,000
Catastrophic Excess Amount: % of Total Claims 29.16% 29.22%
(catastrophic claims as a percentage of total claims)
Net Claims $33,476,427
(total claims less catastrophic excess)
Net Claims: Per Member Per Month $367.50 $308.15 19.26%
Note: Catastrophic Dollars do not include IBNR Claims include IBNR
All Packages/All Sites YTD Qtrly
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 A © Copyright 2017 HealthPartners
400_Ex_Effect_Catastrophic_ClaimsReport Id: 43735
Page 57 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical PMPM Before and After Removing Claims in Excess of Catastrophic Threshold
All Packages/All Sites YTD Qtrly
C CCurrent Year Current Aggregate P Prior Year Prior AggregateP
Report Period: 2/1/2017 12:00:00 ARun Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735400_Ex_Effect_Catastrophic_Claims
Page 58 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Distribution of Claimants and Dollars
Dollar RangeNumber ofClaimants Claims
Cumulative %of Claimants
Cumulative %of Claims
Cumulative %of Claimants
Cumulative %of Claims
1 - 250 960 $107,990 12.75% 0.22% 19.65% 0.35%
250 - 500 753 $279,246 22.74% 0.81% 32.49% 1.27%
500 - 1000 1,161 $844,188 38.16% 2.56% 49.41% 3.65%
1000 - 2500 1,741 $2,861,298 61.27% 8.52% 69.39% 9.89%
2500 - 5000 1,153 $4,081,683 76.58% 17.03% 81.48% 18.15%
5000 - 10000 785 $5,505,076 87.00% 28.49% 89.31% 28.80%
10000 - 15000 317 $3,910,106 91.21% 36.64% 92.82% 37.12%
15000 - 25000 280 $5,402,052 94.93% 47.89% 96.00% 48.95%
25000 - 35000 137 $4,032,976 96.75% 56.29% 97.39% 56.91%
35000 - 50000 96 $3,944,164 98.02% 64.50% 98.36% 64.72%
50000 - 75000 66 $3,840,573 98.90% 72.50% 99.13% 73.66%
75000 - 100000 34 $2,900,994 99.35% 78.54% 99.47% 79.42%
100000 - 125000 17 $1,956,578 99.58% 82.62% 99.65% 83.19%
125000+ 32 $8,345,427 100.00% 100.00% 100.00% 100.00%
7,532 $48,012,348
All Packages/All Sites YTD Qtrly
AggregateCurrent Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
410_Ex_Distribution_of_ClaimantsReport Id: 43735
Page 59 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Distribution of Claimants and Dollars
Dollar RangeNumber ofClaimants Claims
Cumulative %of Claimants
Cumulative %of Claims
Cumulative %of Claimants
Cumulative %of Claims
1 - 250 983 $107,954 13.08% 0.24% 21.08% 0.41%
250 - 500 798 $294,261 23.70% 0.90% 34.35% 1.44%
500 - 1000 1,198 $877,467 39.65% 2.87% 51.34% 4.02%
1000 - 2500 1,740 $2,841,027 62.80% 9.23% 71.06% 10.70%
2500 - 5000 1,152 $4,067,786 78.13% 18.34% 82.55% 19.22%
5000 - 10000 701 $4,903,326 87.46% 29.32% 90.14% 30.42%
10000 - 15000 332 $4,061,936 91.88% 38.42% 93.40% 38.79%
15000 - 25000 262 $5,019,606 95.37% 49.66% 96.32% 50.58%
25000 - 35000 137 $4,026,148 97.19% 58.68% 97.62% 58.57%
35000 - 50000 82 $3,369,975 98.28% 66.22% 98.56% 66.72%
50000 - 75000 59 $3,658,000 99.07% 74.42% 99.24% 75.48%
75000 - 100000 22 $1,862,711 99.36% 78.59% 99.53% 80.73%
100000 - 125000 21 $2,369,845 99.64% 83.90% 99.70% 84.54%
125000+ 27 $7,190,371 100.00% 100.00% 100.00% 100.00%
7,514 $44,650,412
All Packages/All Sites YTD Qtrly
AggregatePrior Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
410_Ex_Distribution_of_ClaimantsReport Id: 43735
Page 60 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Distribution of Member Liability
Member LiabilityDollar Range
Number ofClaimants
MemberLiability Claims
Cumulative %of Claimants
Cumulative % ofMember LIability
Cumulative %of Claims
1 - 250 3,935 $381,175 $4,196,481 52.24% 11.96% 8.74%
250 - 500 1,507 $536,219 $6,257,419 72.25% 28.78% 21.77%
500 - 1000 1,144 $802,424 $9,426,570 87.44% 53.96% 41.41%
1000 - 2500 900 $1,312,105 $25,942,394 99.39% 95.12% 95.44%
2500 - 5000 46 $155,510 $2,189,485 100.00% 100.00% 100.00%
5000 - 10000 0 $0 $0 100.00% 100.00% 100.00%
10000+ 0 $0 $0 100.00% 100.00% 100.00%
Total 7,532 $3,187,434 $48,012,348
All Packages/All Sites YTD Qtrly
Current Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
415_Ex_Distribution_of_Member_LiReport Id: 43735
Page 61 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Distribution of Member Liability
Member LiabilityDollar Range
Number ofClaimants
MemberLiability Claims
Cumulative %of Claimants
Cumulative % ofMember Liability
Cumulative %of Claims
1 - 250 3,976 $388,573 $3,848,421 52.91% 12.48% 8.62%
250 - 500 1,441 $516,337 $5,469,347 72.09% 29.07% 20.87%
500 - 1000 1,165 $823,012 $9,527,654 87.60% 55.50% 42.21%
1000 - 2500 889 $1,234,929 $22,868,655 99.43% 95.17% 93.42%
2500 - 5000 42 $143,738 $2,890,897 99.99% 99.79% 99.90%
5000 - 10000 1 $6,660 $45,439 100.00% 100.00% 100.00%
10000+ 0 $0 $0 100.00% 100.00% 100.00%
Total 7,514 $3,113,249 $44,650,412
All Packages/All Sites YTD Qtrly
Prior Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
415_Ex_Distribution_of_Member_LiReport Id: 43735
Page 62 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsDilated Cardiomyopathy $859,471
Fabry (-anderson) Disease $556,880
Secondary Malignant Neoplasm Of Bone $488,978
Laceration Of Liver, Unspecified Degree, Initial Encounter $448,730
Tetralogy Of Fallot $393,461
Malignant Melanoma Of Skin, Unspecified $335,966
Acute Respiratory Failure With Hypoxia $326,481
Sepsis Due To Methicillin Susceptible Staphylococcus Aureus $324,203
End Stage Renal Disease $315,603
Secondary Malignant Neoplasm Of Other Parts Of Nervous System $287,241
Encounter For Antineoplastic Immunotherapy $286,700
Malignant Neoplasm Of Ascending Colon $286,614
Ulcerative Colitis, Unspecified, Without Complications $266,554
Malignant Neoplasm Of Prostate $203,540Pathological Fracture In Neoplastic Disease, Other Specified Site, Initial Encounter ForFracture $200,597
Postsurgical Lordosis $197,035
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 63 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSt Elevation (stemi) Myocardial Infarction Involving Left Anterior Descending CoronaryArtery $194,777
Benign Neoplasm Of Peripheral Nerves And Autonomic Nervous System Of Abdomen $190,962
Malignant Neoplasm Of Brain, Unspecified $185,472Encounter For Adjustment And Management Of Automatic Implantable CardiacDefibrillator $181,971
Stenosis Of Other Cardiac Prosthetic Devices, Implants And Grafts, Initial Encounter $179,583
Sensitive Diagnosis $171,247
Malignant Neoplasm Of Upper-outer Quadrant Of Right Female Breast $167,742
Unspecified Juvenile Rheumatoid Arthritis Of Unspecified Site $163,761
Malignant Neoplasm Of Pancreas, Unspecified $161,727
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $155,088
Primary Osteoarthritis, Left Shoulder $151,697
Sensitive Diagnosis $140,930
Malignant Neoplasm Of Unspecified Part Of Right Bronchus Or Lung $136,666
Idiopathic Acute Pancreatitis $129,773
Spinal Stenosis, Cervical Region $129,425
Spinal Stenosis, Cervical Region $126,554
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 64 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsNonrheumatic Aortic (valve) Stenosis With Insufficiency $124,852
Obstructive Sleep Apnea (adult) (pediatric) $122,886
Malignant Neoplasm Of Central Portion Of Right Female Breast $121,503
Other Secondary Pulmonary Hypertension $121,232
Malignant Melanoma Of Right Lower Limb, Including Hip $120,915
Spondylolisthesis, Lumbar Region $120,492
Malignant Neoplasm Of Lower-outer Quadrant Of Left Female Breast $120,184
End Stage Renal Disease $116,147
Sepsis, Unspecified Organism $115,629
End Stage Renal Disease $115,366
Malignant Neoplasm Of Upper-outer Quadrant Of Left Female Breast $115,155
Myelodysplastic Syndrome, Unspecified $111,632
Chronic Myeloid Leukemia, Bcr/abl-positive, Not Having Achieved Remission $109,347
Neuromuscular Dysfunction Of Bladder, Unspecified $109,140
Sensitive Diagnosis $105,759
Benign Neoplasm Of Cerebral Meninges $103,981
Malignant Neoplasm Of Overlapping Sites Of Left Female Breast $102,356
Multiple Sclerosis $99,482
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 65 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsUrethral Stricture, Unspecified $96,376
Malignant Neoplasm Of Endometrium $95,034
Sensitive Diagnosis $94,977
Chronic Myeloid Leukemia, Bcr/abl-positive, Not Having Achieved Remission $93,883
Malignant Neoplasm Of Unspecified Site Of Unspecified Female Breast $92,906
Spinal Stenosis, Lumbar Region $92,422
Longitudinal Reduction Defect Of Left Femur $89,566
Non-st Elevation (nstemi) Myocardial Infarction $89,009
Rheumatoid Arthritis Without Rheumatoid Factor, Multiple Sites $88,483
Multiple Sclerosis $88,358
Sensitive Diagnosis $88,159
Sensitive Diagnosis $87,973
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $87,480
Multiple Sclerosis $87,447
Other Spondylosis With Radiculopathy, Lumbar Region $87,235
Anemia, Unspecified $87,108
Type 1 Diabetes Mellitus Without Complications $86,448
Malignant Neoplasm Of Prostate $83,803
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 66 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsPain In Left Knee $83,020
Spinal Stenosis, Cervical Region $82,698
Calculus Of Ureter $81,411
Atherosclerosis Of Native Arteries Of Left Leg With Ulceration Of Other Part Of Foot $80,999
Malignant Neoplasm Of Prostate $80,349
Sepsis, Unspecified Organism $80,102
Multiple Sclerosis $79,230
Type 1 Diabetes Mellitus With Hyperglycemia $78,533
Bilateral Primary Osteoarthritis Of Knee $77,990
Neuromuscular Dysfunction Of Bladder, Unspecified $77,900
Encounter For Screening Mammogram For Malignant Neoplasm Of Breast $77,247
Malignant Neoplasm Of Upper Lobe, Right Bronchus Or Lung $76,826
Other Instability, Right Foot $76,510
Abscess Of Lung With Pneumonia $76,397
Endometriosis Of Pelvic Peritoneum $75,632
Spinal Stenosis, Lumbar Region $74,437
Sensitive Diagnosis $72,205
Unspecified Abdominal Pain $72,081
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 67 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsPseudarthrosis After Fusion Or Arthrodesis $71,575
Fistula Of Stomach And Duodenum $70,548
Malignant Neoplasm Of Prostate $69,787
Neuromuscular Dysfunction Of Bladder, Unspecified $69,762
Occlusion And Stenosis Of Left Carotid Artery $69,322
Crohn's Disease Of Small Intestine Without Complications $67,803
Retention Of Urine, Unspecified $66,484
Sensitive Diagnosis $66,345
Unilateral Primary Osteoarthritis, Right Knee $65,542
Malignant Neoplasm Of Endometrium $64,886
Intramural Leiomyoma Of Uterus $64,796
Sensitive Diagnosis $63,285
Encounter For Antineoplastic Radiation Therapy $62,728
Congenital Malformations Of Intestinal Fixation $61,532
Subserosal Leiomyoma Of Uterus $60,620
Sepsis, Unspecified Organism $59,854Pain Due To Internal Orthopedic Prosthetic Devices, Implants And Grafts, InitialEncounter $59,660
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 68 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsAbdominal Aortic Aneurysm, Without Rupture $59,623Pain Due To Internal Orthopedic Prosthetic Devices, Implants And Grafts, InitialEncounter $59,281
Encounter For Screening For Malignant Neoplasm Of Colon $58,526
Other Spondylosis With Radiculopathy, Cervical Region $58,417
Malignant Neoplasm Of Appendix $57,994
Sensitive Diagnosis $57,663
Type 1 Diabetes Mellitus With Ketoacidosis Without Coma $57,560
Diaphragmatic Hernia Without Obstruction Or Gangrene $57,362
Malignant Carcinoid Tumor Of The Bronchus And Lung $57,357
Cleft Palate, Unspecified $57,275
Rheumatoid Arthritis, Unspecified $57,183
Sensitive Diagnosis $57,013
Encounter For Antineoplastic Radiation Therapy $56,604
Unilateral Post-traumatic Osteoarthritis, Right Knee $56,370
Unspecified Hydronephrosis $55,877
Unspecified Iridocyclitis $55,726
Diarrhea, Unspecified $55,642
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 69 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsOsteomyelitis, Unspecified $55,575
Other Pneumothorax $55,544
Malignant Neoplasm Of Frontal Lobe $55,242
Inflammatory Polyarthropathy $54,984
Rheumatoid Arthritis, Unspecified $54,688
Vesicointestinal Fistula $54,384
Sensitive Diagnosis $54,269
Sensitive Diagnosis $54,032
Non-st Elevation (nstemi) Myocardial Infarction $53,636
Complete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $53,482
Infection Following A Procedure, Initial Encounter $53,229
Unilateral Primary Osteoarthritis, Left Hip $53,158
Non-st Elevation (nstemi) Myocardial Infarction $53,005
Multiple Sclerosis $52,852
Juvenile Rheumatoid Polyarthritis (seronegative) $52,740
Radiculopathy, Cervical Region $52,556
Chronic Ethmoidal Sinusitis $52,542
Precocious Puberty $52,532
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 70 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsOsteoarthritis Of Knee, Unspecified $52,490
Cystic Fibrosis, Unspecified $52,037
Plantar Fascial Fibromatosis $52,016Atherosclerotic Heart Disease Of Native Coronary Artery With Other Forms Of AnginaPectoris $51,551
Malignant Neoplasm Of Cervix Uteri, Unspecified $51,320
Sensitive Diagnosis $51,053
Psoriasis Vulgaris $50,925
Gastrostomy Status $50,754
Obstructive Sleep Apnea (adult) (pediatric) $50,670
Sprain Of Anterior Cruciate Ligament Of Left Knee, Initial Encounter $50,366
Calculus Of Gallbladder With Acute Cholecystitis With Obstruction $50,212
Sensitive Diagnosis $49,892
Acute On Chronic Systolic (congestive) Heart Failure $48,854
Malignant Neoplasm Of Unspecified Site Of Left Female Breast $48,639
Acute Serous Otitis Media, Bilateral $48,277
Unilateral Primary Osteoarthritis, Right Hip $48,034
Other Specified Rheumatoid Arthritis, Multiple Sites $47,462
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 71 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsMigraine Without Aura, Intractable, Without Status Migrainosus $47,330
Streptococcus B Carrier State Complicating Childbirth $47,122
Benign Neoplasm Of Pituitary Gland $47,032
Unilateral Primary Osteoarthritis, Right Knee $46,947
Rheumatoid Arthritis With Rheumatoid Factor, Unspecified $46,928
Arthropathic Psoriasis, Unspecified $46,604
Non-st Elevation (nstemi) Myocardial Infarction $46,168
Cerebral Infarction, Unspecified $46,140
Unilateral Primary Osteoarthritis, Right Knee $45,946
Sensitive Diagnosis $45,862
Diaphragmatic Hernia Without Obstruction Or Gangrene $45,768
Other Cervical Disc Degeneration, Mid-cervical Region $45,652
Unilateral Primary Osteoarthritis, Left Knee $45,591
Stenosis Of Other Cardiac Prosthetic Devices, Implants And Grafts, Initial Encounter $45,127
Arthropathic Psoriasis, Unspecified $44,328
Malignant Neoplasm Of Prostate $44,313
Unilateral Primary Osteoarthritis, Right Hip $44,286
Sensitive Diagnosis $44,076
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 72 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $43,897
Calculus Of Kidney $43,861
Primary Pulmonary Hypertension $43,748
Other Cyst Of Bone, Other Site $43,626
Sensitive Diagnosis $43,607
Embolism And Thrombosis Of Arteries Of The Lower Extremities $43,413
Unilateral Primary Osteoarthritis, Left Hip $43,312
Acute Respiratory Failure With Hypoxia $43,311
Edema, Unspecified $43,294
Crohn's Disease Of Small Intestine With Other Complication $43,253
Encounter For Screening For Malignant Neoplasm Of Colon $42,445
Encounter For Antineoplastic Immunotherapy $42,387
Intestinal Adhesions [bands] With Obstruction (postprocedural) (postinfection) $42,345
Pericardial Effusion (noninflammatory) $41,976
Type 1 Diabetes Mellitus With Hyperglycemia $41,970
Other Chronic Pain $41,738
Benign Neoplasm Of Right Ovary $41,538
Lesion Of Plantar Nerve, Right Lower Limb $41,495
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 73 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsGastro-esophageal Laceration-hemorrhage Syndrome $41,403
Sepsis Due To Hemophilus Influenzae $40,922
Osteoarthritis Of Knee, Unspecified $40,764
Other Specified Diabetes Mellitus With Ketoacidosis Without Coma $40,596Strain Of Other Specified Muscles, Fascia And Tendons At Thigh Level, Right Thigh,Initial Encounter $40,567
Benign Neoplasm Of Parathyroid Gland $40,468
Pseudarthrosis After Fusion Or Arthrodesis $40,397
Unspecified Atrial Flutter $40,351
Other Cervical Disc Displacement, Mid-cervical Region $40,101
Family History Of Ischemic Heart Disease And Other Diseases Of The Circulatory System $39,998
Sensitive Diagnosis $39,866
Unilateral Primary Osteoarthritis, Right Knee $39,772
Arthropathic Psoriasis, Unspecified $39,542
Induration Penis Plastica $39,232
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $39,079
Unspecified Fracture Of Lower End Of Right Tibia, Initial Encounter For Closed Fracture $39,059
Sensitive Diagnosis $39,048
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 74 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnspecified Sequelae Of Unspecified Cerebrovascular Disease $38,954
Osteoarthritis Of Knee, Unspecified $38,952
Morbid (severe) Obesity Due To Excess Calories $38,717
Hydronephrosis With Renal And Ureteral Calculous Obstruction $38,714
Sensitive Diagnosis $38,556
Benign Neoplasm, Unspecified Site $38,503
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $38,452
Esophageal Varices Without Bleeding $38,247
Unspecified Cataract $38,164
Sensitive Diagnosis $38,116
Malignant Neoplasm Of Endometrium $38,073
Unilateral Primary Osteoarthritis, Right Hip $37,958
Other Internal Derangements Of Left Knee $37,935
Unilateral Primary Osteoarthritis, Right Knee $37,854
Other Cervical Disc Displacement, Mid-cervical Region $37,738
Sensitive Diagnosis $37,724
Infection Following A Procedure, Initial Encounter $37,718
Unilateral Primary Osteoarthritis, Left Knee $37,657
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 75 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther Chest Pain $37,584
Paroxysmal Atrial Fibrillation $37,359
Sensitive Diagnosis $37,256
Dissection Of Other Specified Artery $36,824
Sensitive Diagnosis $36,706
Precocious Puberty $36,671
Other Acute Postprocedural Pain $36,550
Other Specified Types Of Non-hodgkin Lymphoma, Extranodal And Solid Organ Sites $36,434
Unilateral Primary Osteoarthritis, Left Hip $36,220
Excessive And Frequent Menstruation With Irregular Cycle $35,899
Delayed Milestone In Childhood $35,893
Streptococcal Sepsis, Unspecified $35,780
Osteoarthritis Of Knee, Unspecified $35,725
Leiomyoma Of Uterus, Unspecified $35,633
Sensitive Diagnosis $35,471
Type 2 Diabetes Mellitus Without Complications $35,469
Unilateral Primary Osteoarthritis, Left Hip $35,395
Other Secondary Cataract, Left Eye $35,301
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 76 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther Ascites $35,206
Other Specified Disorders Of Eyelid $34,988
Morbid (severe) Obesity Due To Excess Calories $34,928
Excessive And Frequent Menstruation With Irregular Cycle $34,822
End Stage Renal Disease $34,679
Leiomyoma Of Uterus, Unspecified $34,564
Bilateral Primary Osteoarthritis Of Knee $34,549
Unilateral Primary Osteoarthritis, Left Knee $34,464
Poisoning By Propionic Acid Derivatives, Intentional Self-harm, Initial Encounter $34,448
Other Noninflammatory Disorders Of Ovary, Fallopian Tube And Broad Ligament $34,434
Dizziness And Giddiness $34,010
Dry Eye Syndrome Of Bilateral Lacrimal Glands $33,991
Sensitive Diagnosis $33,864
Guillain-barre Syndrome $33,828
Rheumatoid Arthritis With Rheumatoid Factor, Unspecified $33,669
Acute Appendicitis With Generalized Peritonitis $33,646
Malignant Neoplasm Of Thyroid Gland $33,644
Malignant Neoplasm Of Prostate $33,417
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 77 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Therapeutic Drug Level Monitoring $33,408
Unspecified Atrial Fibrillation $33,183
Rheumatoid Arthritis Without Rheumatoid Factor, Multiple Sites $33,106
Sprain Of Anterior Cruciate Ligament Of Right Knee, Initial Encounter $33,040
Unilateral Primary Osteoarthritis, Right Knee $33,004
Sensitive Diagnosis $32,922
Unilateral Primary Osteoarthritis, Right Knee $32,879
Anemia, Unspecified $32,869Displaced Intraarticular Fracture Of Right Calcaneus, Initial Encounter For ClosedFracture $32,769
Unilateral Primary Osteoarthritis, Right Knee $32,620
Unilateral Primary Osteoarthritis, Right Knee $32,548
Intervertebral Disc Disorders With Radiculopathy, Lumbar Region $32,391
Disruptive Mood Dysregulation Disorder $32,292
Displacement Of Intraocular Lens, Initial Encounter $32,203
Unilateral Primary Osteoarthritis, Left Knee $32,145
Osteoarthritis Of Knee, Unspecified $32,106
Chronic Ethmoidal Sinusitis $32,046
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 78 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsInfections Of Kidney In Pregnancy, Third Trimester $32,014
Benign Neoplasm Of Left Ovary $31,995
Sensorineural Hearing Loss, Bilateral $31,850
Unilateral Primary Osteoarthritis, Left Knee $31,780
Other Specified Diseases Of Intestine $31,581
Sensitive Diagnosis $31,578
Ulcerative (chronic) Pancolitis Without Complications $31,494
Vascular Disorder Of Intestine, Unspecified $31,372
Sensitive Diagnosis $31,275
Benign Neoplasm Of Ascending Colon $31,242
Sensitive Diagnosis $31,204
Bilateral Primary Osteoarthritis Of Knee $31,185
Maternal Care For Breech Presentation, Fetus 1 $31,133
Sensitive Diagnosis $30,990
Unilateral Primary Osteoarthritis, Right Knee $30,652
Supraventricular Tachycardia $30,526
Unspecified Lump In Breast $30,219
Unilateral Primary Osteoarthritis, Right Hip $30,195
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 79 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsAtherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $30,162
Unspecified Osteoarthritis, Unspecified Site $30,128
Atypical Atrial Flutter $30,121
Incisional Hernia Without Obstruction Or Gangrene $30,120
Incomplete Rotator Cuff Tear Or Rupture Of Left Shoulder, Not Specified As Traumatic $30,077
Pre-existing Type 2 Diabetes Mellitus, In Childbirth $29,908
Hyperlipidemia, Unspecified $29,895Other Generalized Epilepsy And Epileptic Syndromes, Not Intractable, Without StatusEpilepticus $29,894
Obstructed Labor Due To Breech Presentation, Fetus 1 $29,801
Dermatochalasis Of Right Upper Eyelid $29,750
Sensitive Diagnosis $29,698
Malignant Neoplasm Of Lower-outer Quadrant Of Left Female Breast $29,634
Thrombotic Microangiopathy $29,564
Chronic Or Unspecified Gastrojejunal Ulcer With Hemorrhage $29,490
Bilateral Inguinal Hernia, Without Obstruction Or Gangrene, Not Specified As Recurrent $29,477
Unspecified Abnormalities Of Gait And Mobility $29,309
Morbid (severe) Obesity Due To Excess Calories $29,206
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 80 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Other Preprocedural Examination $29,127
Sensitive Diagnosis $28,995
Primary Osteoarthritis, Left Shoulder $28,968Other Intraarticular Fracture Of Lower End Of Right Radius, Initial Encounter For ClosedFracture $28,963
Sensitive Diagnosis $28,955
Sensitive Diagnosis $28,857
Deviated Nasal Septum $28,815
Sensitive Diagnosis $28,626
Unilateral Primary Osteoarthritis, Right Hip $28,569
Other Abnormal Involuntary Movements $28,558
Unilateral Inguinal Hernia, Without Obstruction Or Gangrene, Not Specified As Recurrent $28,523Displaced Fracture Of Lateral Malleolus Of Left Fibula, Initial Encounter For ClosedFracture $28,349
Respiratory Distress Of Newborn, Unspecified $28,332
Morbid (severe) Obesity Due To Excess Calories $28,208
Hypothyroidism, Unspecified $28,033
Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Left Cerebellar Artery $27,968
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 81 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $27,839
Benign Neoplasm Of Left Ovary $27,831
Right Lower Quadrant Pain $27,612
Sensitive Diagnosis $27,608
Benign Lipomatous Neoplasm Of Intra-abdominal Organs $27,600
Headache $27,503
Unilateral Primary Osteoarthritis, Right Knee $27,442
Neoplasm Of Uncertain Behavior Of Left Ovary $27,268
Unilateral Primary Osteoarthritis, Left Knee $27,221
Ganglion, Right Wrist $27,196
Incomplete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $27,105
Sensitive Diagnosis $27,069
Sensitive Diagnosis $27,048
Sensitive Diagnosis $27,037
Osteoarthritis Of Knee, Unspecified $27,036
Sensitive Diagnosis $26,922
Other Iron Deficiency Anemias $26,826
Calculus Of Ureter $26,814
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 82 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $26,765
Carpal Tunnel Syndrome, Right Upper Limb $26,738
Right Upper Quadrant Pain $26,724
Cervical Shortening, Second Trimester $26,700
Other Specified Diseases Of Gallbladder $26,599
Malignant Neoplasm Of Left Ovary $26,557
Spondylosis Without Myelopathy Or Radiculopathy, Lumbar Region $26,451
Other Specified Diseases Of Gallbladder $26,395
Calculus Of Gallbladder And Bile Duct With Cholecystitis, Unspecified, With Obstruction $26,331
Other Postprocedural Complications And Disorders Of Nervous System $26,297
Urticaria, Unspecified $26,278
Morbid (severe) Obesity Due To Excess Calories $26,231
Ankylosing Spondylitis Of Multiple Sites In Spine $25,984
Persistent Atrial Fibrillation $25,933
Obstructive Sleep Apnea (adult) (pediatric) $25,730
Sensitive Diagnosis $25,714
Unilateral Primary Osteoarthritis, Left Hip $25,702
Sensitive Diagnosis $25,667
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 83 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsParkinson's Disease $25,600
Chronic Or Unspecified Duodenal Ulcer With Perforation $25,584
Displaced Fracture Of Shaft Of Left Clavicle, Initial Encounter For Closed Fracture $25,543
Other Spondylosis With Radiculopathy, Lumbar Region $25,537
Precocious Puberty $25,514
Sensitive Diagnosis $25,497
Sensitive Diagnosis $25,410
Lumbago With Sciatica, Right Side $25,401
Sensitive Diagnosis $25,377
Obstructive Sleep Apnea (adult) (pediatric) $25,328
Alcoholic Hepatitis With Ascites $25,210
Hydronephrosis With Renal And Ureteral Calculous Obstruction $25,182Atherosclerotic Heart Disease Of Native Coronary Artery With Unspecified AnginaPectoris $25,094
Calculus Of Kidney With Calculus Of Ureter $25,046
Sensitive Diagnosis $25,031
Unspecified Dislocation Of Right Acromioclavicular Joint, Initial Encounter $25,010
Total $25,020,710
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 84 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis Claims
Total Above $25,000 $15,470,710
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 85 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsSubarachnoid Hemorrhage $851,373
Lipidoses $558,515
Sensitive Diagnosis $470,687
Malignant Neoplasm Of Upper Lobe, Bronchus Or Lung $408,230
Malignant Neoplasm Of Ascending Colon $347,367
Sensitive Diagnosis $338,684
Acute And Chronic Respiratory Failure $303,079
Sensitive Diagnosis $301,931
Spinal Stenosis In Cervical Region $298,704
Encounter For Antineoplastic Chemotherapy $276,372
Sensitive Diagnosis $262,816
Malignant Melanoma Of Skin, Unspecified $225,468
Polyarticular Juvenile Rheumatoid Arthritis, Chronic Or Unspecified $207,913
Acute Lymphoid Leukemia, Without Mention Of Having Achieved Remission $206,067
Malignant Neoplasm Of Breast (female), Unspecified $201,035
End Stage Renal Disease $187,889
Malignant Neoplasm Of Rectum $187,472
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 86 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Antineoplastic Chemotherapy $179,408
Atrial Fibrillation $171,844
Other Malignant Neoplasm Of Unspecified Site $168,269
Malignant Neoplasm Of Kidney, Except Pelvis $161,081
Malignant Melanoma Of Skin Of Upper Limb, Including Shoulder $159,719
Malignant Neoplasm Of Breast (female), Unspecified $154,779
Anemia Of Other Chronic Disease $147,336
Encounter For Antineoplastic Immunotherapy $143,711
Encounter For Antineoplastic Chemotherapy $137,180
Spondylolisthesis, Congenital $133,443
Iliotibial Band Syndrome, Right Leg $124,234
Sensitive Diagnosis $124,081
Other Mechanical Complication Of Other Internal Orthopedic Device, Implant, And Graft $123,687
Malignant Neoplasm Of Prostate $123,523
Sensitive Diagnosis $120,508
End Stage Renal Disease $118,254
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $117,577
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 87 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsAtrial Fibrillation $115,869
End Stage Renal Disease $115,331
Other Ankle Sprain And Strain $114,431
Coronary Atherosclerosis Of Native Coronary Vessel $113,103
Contracture, Left Elbow $110,717
End Stage Renal Disease $110,575
Sensitive Diagnosis $110,534
Malignant Neoplasm Of Other Specified Sites Of Female Breast $109,855
Malignant Neoplasm Of Prostate $104,998
Sensitive Diagnosis $103,588
Trigeminal Neuralgia $103,534
Coronary Atherosclerosis Of Native Coronary Vessel $102,675
Sensitive Diagnosis $102,132
Chronic Or Unspecified Parametritis And Pelvic Cellulitis $100,640
Malignant Neoplasm Of Pancreas, Part Unspecified $99,819
Acute And Chronic Respiratory Failure $99,186
Orchitis And Epididymitis, Unspecified $95,329
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 88 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsChronic Myeloid Leukemia, Without Mention Of Having Achieved Remission $93,657
Other Hammer Toe (acquired) $93,028
Quadriplegia, C5-c7, Incomplete $88,174
Sensitive Diagnosis $86,651
Multiple Sclerosis $85,544
Multiple Sclerosis $83,894
Malignant Carcinoid Tumor Of The Small Intestine, Unspecified Portion $83,560
Atrial Fibrillation $83,280
Nonunion Of Fracture $83,031
Radiculopathy, Lumbar Region $82,624
Multiple Sclerosis $82,549
Sensitive Diagnosis $80,560
Sensitive Diagnosis $80,159
Malignant Neoplasm Of Lower Lobe, Bronchus Or Lung $78,194
Encounter For Antineoplastic Radiation Therapy $78,122
Hypertrophy Of Breast $77,680
Regional Enteritis Of Small Intestine $76,282
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 89 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsCoronary Atherosclerosis Of Native Coronary Vessel $76,212
Volvulus $75,175
Acute Myocardial Infarction, Subendocardial Infarction, Initial Episode Of Care $74,885
Regional Enteritis Of Small Intestine With Large Intestine $74,801
Multiple Sclerosis $74,535
Sensitive Diagnosis $74,088
Multiple Sclerosis $73,636
Unspecified Chest Pain $72,287
Fitting And Adjustment Of Automatic Implantable Cardiac Defibrillator $72,149
Other Polyp Of Sinus $71,379
Sensitive Diagnosis $70,970
Sensitive Diagnosis $70,651
Retention Of Urine, Unspecified $69,713
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $69,475
Sensitive Diagnosis $69,097
Other B-complex Deficiencies $68,689
Bilateral Partial Paralysis Of Vocal Cords Or Larynx $68,642
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 90 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsCalculus Of Kidney $68,431
Rheumatic Fever Without Heart Involvement $68,283
Supraventricular Tachycardia $68,265
Encounter For Antineoplastic Chemotherapy $67,980
Leukoplakia Of Oral Mucosa, Including Tongue $67,832
Sensitive Diagnosis $67,594
Type 1 Diabetes Mellitus Without Complications $67,326
Rectal Prolapse $66,271
Sensitive Diagnosis $65,450
Hallux Valgus (acquired) $63,616
Closed Fracture Of Humerus, Supracondylar $63,502
Coronary Atherosclerosis Of Native Coronary Vessel $63,182Unspecified Disorders Of Menstruation And Other Abnormal Bleeding From FemaleGenital Tract $63,127
Sensitive Diagnosis $63,091
Coronary Atherosclerosis Of Native Coronary Vessel $62,920
Sensitive Diagnosis $62,406
Other Primary Cardiomyopathies $62,238
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 91 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsBell's Palsy $60,179
Cortical Age-related Cataract, Left Eye $59,294
Sensitive Diagnosis $59,205
Open Bite Of Left Thumb Without Damage To Nail, Initial Encounter $58,871
Regional Enteritis Of Small Intestine With Large Intestine $57,715
Craniosynostosis $57,678
Malignant Neoplasm Of Ovary $57,005
Other Complications Due To Internal Joint Prosthesis $56,836
Acute Systolic (congestive) Heart Failure $56,779
Atherosclerosis Of Native Arteries Of Extremities With Ulceration $55,800
Eosinophilia $55,724
Other Mechanical Complication Of Cardiac Electrode, Initial Encounter $55,214
Encounter For Breast Reconstruction Following Mastectomy $54,951
Other And Unspecified Creutzfeldt-jakob Disease $54,832
Sensitive Diagnosis $54,228
Multiple Sclerosis $54,162
Cystic Fibrosis Without Mention Of Meconium Ileus $52,860
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 92 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsNonpyogenic Meningitis $51,993Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $51,833
Acute Osteomyelitis, Ankle And Foot $51,272
Other Chest Pain $51,250
Displacement Of Lumbar Intervertebral Disc Without Myelopathy $51,200Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $51,066
Morbid (severe) Obesity Due To Excess Calories $50,706
Encephalocele $50,626
Deviated Nasal Septum $50,151
Rheumatoid Arthritis $50,062
Rheumatoid Arthritis $48,734
Unspecified Ventral Hernia Without Mention Of Obstruction Or Gangrene $48,583
Sensitive Diagnosis $48,154
Cellulitis Of Right Toe $47,732
Neuralgia, Neuritis, And Radiculitis, Unspecified $47,656
Other Allied Disorders Of Spine $47,536
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 93 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsMorbid Obesity $47,517
Cirrhosis Of Liver Without Mention Of Alcohol $47,492
Coronary Atherosclerosis Of Native Coronary Vessel $47,276
Hodgkin's Disease, Nodular Sclerosis, Unspecified Site, Extranodal And Solid Organ Sites $47,255
Sensitive Diagnosis $46,360
Other Specified Diseases Of Pancreas $46,273
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $46,267
Sensitive Diagnosis $46,195
Encounter For Antineoplastic Radiation Therapy $45,814
Sensitive Diagnosis $45,806
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $45,760
Sensitive Diagnosis $45,439
Osteoarthrosis, Localized, Primary, Lower Leg $45,413
Unspecified Iridocyclitis $45,355
Sensitive Diagnosis $45,125
Unspecified Inflammatory Polyarthropathy $44,987
Sensitive Diagnosis $44,408
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 94 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsPrecocious Sexual Development And Puberty, Not Elsewhere Classified $44,195
Acute Myocardial Infarction, Subendocardial Infarction, Initial Episode Of Care $43,669
Incomplete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $43,662
Malignant Neoplasm Of Rectum $43,268
Other Pulmonary Embolism And Infarction $42,818
Malignant Neoplasm Of Upper-outer Quadrant Of Female Breast $42,756
Acute Myocardial Infarction, Of Other Anterior Wall, Initial Episode Of Care $42,088
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $41,809
Coronary Atherosclerosis Of Native Coronary Vessel $41,686
Unspecified Chest Pain $41,510
Sensitive Diagnosis $41,468
Sensitive Diagnosis $41,466
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $41,443
Other Psoriasis $41,442
Deviated Nasal Septum $41,272
Malignant Neoplasm Of Ovary $41,252
Syncope And Collapse $41,224
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 95 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnilateral Primary Osteoarthritis, Right Knee $40,835
Malignant Neoplasm Of Upper-outer Quadrant Of Left Female Breast $40,535Atherosclerotic Heart Disease Of Native Coronary Artery With Other Forms Of AnginaPectoris $40,443
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $40,242
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $40,188
Sensitive Diagnosis $39,926Displaced Fracture Of Acromial Process, Left Shoulder, Initial Encounter For ClosedFracture $39,896
Unilateral Primary Osteoarthritis, Left Knee $39,889
Diabetes Mellitus Without Mention Of Complication, Type I [juvenile Type], Uncontrolled $39,783
Post-traumatic Headache, Unspecified, Not Intractable $39,595
Unilateral Primary Osteoarthritis, Left Knee $39,514
Calculus Of Bile Duct Without Cholangitis Or Cholecystitis Without Obstruction $39,220
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $38,914
Primary Focal Hyperhidrosis $38,812
Other Selective Immunoglobulin Deficiencies $38,399
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $38,305
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 96 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsIncisional Hernia Without Mention Of Obstruction Or Gangrene $38,264
Displacement Of Cervical Intervertebral Disc Without Myelopathy $38,078
Calculus Of Gallbladder And Bile Duct With Acute Cholecystitis Without Obstruction $38,014Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, ShoulderRegion $37,882
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $37,521
Diverticulitis Of Colon (without Mention Of Hemorrhage) $37,488
Acute On Chronic Systolic Heart Failure $37,406
Sensitive Diagnosis $37,222
Acute Myocardial Infarction, Subendocardial Infarction, Initial Episode Of Care $37,172
End Stage Renal Disease $36,516
Supraventricular Tachycardia $36,215
Morbid Obesity $36,136
Sensitive Diagnosis $36,115
Osteoarthrosis, Unspecified Whether Generalized Or Localized, Hand $36,030
Other Polyp Of Sinus $35,989
Displacement Of Lumbar Intervertebral Disc Without Myelopathy $35,968
Acute Kidney Failure, Unspecified $35,910
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 97 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $35,884
Urticaria, Unspecified $35,741
Thrombotic Microangiopathy $35,678
Rheumatoid Arthritis $35,527
Closed Fracture Of C5-c7 Level With Unspecified Spinal Cord Injury $35,445
Sensitive Diagnosis $35,370
Synovitis And Tenosynovitis, Unspecified $35,327
Solitary Pulmonary Nodule $35,213
Malignant Neoplasm Of Prostate $35,207
Ulcerative Colitis, Unspecified $34,844
Acute Myocardial Infarction, Subendocardial Infarction, Initial Episode Of Care $34,783
Polyarticular Juvenile Rheumatoid Arthritis, Chronic Or Unspecified $34,737
Supraventricular Tachycardia $34,445
Unspecified Septicemia $34,400
Sensitive Diagnosis $34,272
Postprocedural Intestinal Obstruction $34,159
Multiple Sclerosis $33,774
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 98 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsCoronary Atherosclerosis Of Native Coronary Vessel $33,737
Sprain Of Right Rotator Cuff Capsule, Initial Encounter $33,676
Unspecified Disorder Of Male Genital Organs $33,636
Sensitive Diagnosis $33,624
Ventral Hernia Without Obstruction Or Gangrene $33,477
Encounter For Checking And Testing Of Cardiac Pacemaker Pulse Generator [battery] $33,418
Deviated Nasal Septum $33,414
Morbid (severe) Obesity Due To Excess Calories $33,407
Calculus Of Kidney $33,357
Urinary Tract Infection, Site Not Specified $33,273
Sinoatrial Node Dysfunction $33,157
Hallux Valgus (acquired) $33,153
Occlusion And Stenosis Of Carotid Artery Without Mention Of Cerebral Infarction $33,106Diabetes With Unspecified Complication, Type I [juvenile Type], Not Stated AsUncontrolled $33,055
Sensitive Diagnosis $32,930
Closed Trimalleolar Fracture $32,856
Loss Of Weight $32,849
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 99 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther Postoperative Infection $32,723Diabetes With Neurological Manifestations, Type I [juvenile Type], Not Stated AsUncontrolled $32,660
Sensitive Diagnosis $32,636
Sensitive Diagnosis $32,620
Sensitive Diagnosis $32,498
Sensitive Diagnosis $32,488
Umbilical Hernia Without Mention Of Obstruction Or Gangrene $32,476
Sensitive Diagnosis $32,431Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $32,190
Sensitive Diagnosis $32,135
Abdominal Pain, Unspecified Site $31,948
Other Psoriasis $31,790
Osteoporosis, Unspecified $31,777
Obstructive Hydrocephalus $31,657
Calculus Of Kidney $31,430
Sensitive Diagnosis $31,328
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 100 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsCervicalgia $31,027Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $30,916
Displacement Of Cervical Intervertebral Disc Without Myelopathy $30,899
Acute On Chronic Systolic Heart Failure $30,835
Sensitive Diagnosis $30,819
Other Polyp Of Sinus $30,805
Osteoarthritis Of Knee, Unspecified $30,742
Sensitive Diagnosis $30,682
Sensitive Diagnosis $30,483
Chronic Ethmoidal Sinusitis $30,414
Hidradenitis $30,406
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $30,398
Coronary Atherosclerosis Of Native Coronary Vessel $30,348
Unspecified Site Of Foot Sprain And Strain $30,287
Sensitive Diagnosis $30,026
Excessive And Frequent Menstruation With Irregular Cycle $30,020
Morbid Obesity $29,994
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 101 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsHyperparathyroidism, Unspecified $29,909
Sensitive Diagnosis $29,899
Unilateral Primary Osteoarthritis, Right Knee $29,766
Other Inflammatory Disorders Of Male Genital Organs $29,648
Sensitive Diagnosis $29,453
Hairy Cell Leukemia Not Having Achieved Remission $29,382
Type 1 Diabetes Mellitus With Diabetic Neuropathy, Unspecified $29,206
Other Chest Pain $29,141
Pain In Limb $29,073
Hypogammaglobulinemia, Unspecified $29,040
Primary Pulmonary Hypertension $29,011
Hydronephrosis With Renal And Ureteral Calculous Obstruction $29,006
Sensitive Diagnosis $28,931
Postmenopausal Bleeding $28,894
Calculus Of Bile Duct With Acute And Chronic Cholecystitis Without Obstruction $28,819
Leiomyoma Of Uterus, Unspecified $28,775
Persistent Atrial Fibrillation $28,771
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 102 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Removal Of Internal Fixation Device $28,696
Sensitive Diagnosis $28,633
Hypertrophy Of Nasal Turbinates $28,339Nonspecific (abnormal) Findings On Radiological And Other Examination Of GenitourinaryOrgans $28,311
Poisoning By Other And Unspecified Anticonvulsants $28,092
Pelvic Peritoneal Adhesions, Female (postoperative) (postinfection) $28,028
Ankylosing Spondylitis $28,027Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, ShoulderRegion $27,886
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $27,808
Sensitive Diagnosis $27,657
Multiple Sclerosis $27,604
Supraspinatus (muscle) (tendon) Sprain And Strain $27,459
Sensitive Diagnosis $27,431
Cervicalgia $27,415
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $27,356
Morbid Obesity $27,348
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 103 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsMechanical Complication Due To Corneal Graft $27,283
Care Involving Other Physical Therapy $27,230
Sensitive Diagnosis $27,203
Sensitive Diagnosis $27,148
Leiomyoma Of Uterus, Unspecified $27,093Localization-related (focal) (partial) Symptomatic Epilepsy And Epileptic Syndromes WithSimple Partial Seizures, Not Intractable, With Status Epilepticus $27,088
Febrile Convulsions (simple), Unspecified $27,077
Bicipital Tendinitis, Right Shoulder $27,002
Calculus Of Gallbladder With Chronic Cholecystitis Without Obstruction $26,996
Other Chronic Nonalcoholic Liver Disease $26,842
Flatulence, Eructation, And Gas Pain $26,806
Loose Body In Ankle And Foot Joint $26,759
Cardiac Murmur, Unspecified $26,712
Sensitive Diagnosis $26,668
Acute And Chronic Respiratory Failure $26,627
Sensitive Diagnosis $26,596
Non-st Elevation (nstemi) Myocardial Infarction $26,534
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 104 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsOsteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $26,528
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $26,505
Osteoarthrosis, Localized, Primary, Lower Leg $26,500
Acute Pancreatitis, Unspecified $26,475
Spinal Stenosis, Lumbar Region, Without Neurogenic Claudication $26,432
Unspecified Chest Pain $26,265
Dermatochalasis $26,212
Diaphragmatic Hernia Without Mention Of Obstruction Or Gangrene $26,156
Rheumatoid Arthritis $26,133
Hypo-osmolality And Hyponatremia $26,102
Lumbosacral Spondylosis Without Myelopathy $25,968
Mandibular Hyperplasia $25,941
Closed Fractures Of Other Part Of Distal End Of Radius (alone) $25,924
Calculus Of Gallbladder With Chronic Cholecystitis Without Obstruction $25,916
Acute Myocardial Infarction, Unspecified Site, Subsequent Episode Of Care $25,896
Articular Cartilage Disorder, Pelvic Region And Thigh $25,839
Posterior Subcapsular Polar Senile Cataract $25,791
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 105 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsNontraumatic Subacute Subdural Hemorrhage $25,739
Calculus Of Gallbladder With Other Cholecystitis, Without Mention Of Obstruction $25,717
Psoriasis Vulgaris $25,628
Sprain And Strain Of Other Specified Sites Of Hip And Thigh $25,626
Sensitive Diagnosis $25,625
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $25,578
Lesion Of Ulnar Nerve, Left Upper Limb $25,483Laceration Without Foreign Body Of Left Ring Finger Without Damage To Nail, InitialEncounter $25,481
Epilepsy, Unspecified, Without Mention Of Intractable Epilepsy $25,265
Unspecified Intestinal Obstruction $25,257
Sensitive Diagnosis $25,232
Hypoparathyroidism $25,028
Total $22,477,050
Total Above $25,000 $13,777,050
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 106 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Expenditure Summary
Service Category Claims PMPMAggregate
PMPMVariance in
PMPMPMPMTrend
Professional $21,284,758 $233.56 $172.17 35.65% 12.19%
Hospital IP $9,167,229 $100.59 $91.03 10.51% 16.34%
Hospital OP $10,562,345 $115.90 $103.74 11.72% 1.35%
Pharmacy $9,298,655 $102.04 $79.08 29.02% 3.06%
DME, Transportation, Other $1,135,349 $12.46 $10.98 13.45% 16.12%
Preventive/Accidental Dental $0 $0.00 $1.39 -100.00% 0.00%
Total $51,448,336 $564.55 $458.40 23.16% 8.83%
All Packages/All Sites YTD Qtrly
Claims include IBNR
Note: The Aggregate PMPM for Preventive Dental services reflects the cost for coverage of children only.
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
100_Ex_Expenditure_SummaryReport Id: 43735
Page 1 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Expenditure Summary
Service Category Claims PMPMAggregate
PMPMVariance in
PMPM
Professional $18,963,874 $208.18 $163.09 27.65%
Hospital IP $7,876,114 $86.46 $84.93 1.80%
Hospital OP $10,417,203 $114.36 $99.67 14.74%
Pharmacy $9,019,153 $99.01 $76.16 30.00%
DME, Transportation, Other $977,133 $10.73 $10.18 5.39%
Preventive/Accidental Dental $0 $0.00 $1.30 -100.00%
Total $47,253,477 $518.74 $435.33 19.16%
All Packages/All Sites YTD Qtrly
Claims include IBNR
Note: The Aggregate PMPM for Preventive Dental services reflects the cost for coverage of children only.
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
100_Ex_Expenditure_SummaryReport Id: 43735
Page 2 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Per Member Per Month Comparisons
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
100_Ex_Expenditure_SumReport Id: 43735
Page 3 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional Utilization by Major Practice Category
Major Practice Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid PerUnit PMPM
Variancein PMPM
PMPMTrend
Orthopedic and Arthritic Conditions $3,136,694.74 10.369 $39.83 $34.42 10.293 $33.12 $28.41 21.15% 1.06%Cancer $2,201,522.91 5.630 $51.49 $24.16 5.372 $31.70 $14.19 70.20% 50.25%Psychiatry $1,823,217.67 3.172 $75.68 $20.01 2.797 $62.19 $14.50 38.01% 4.87%Cardiology $1,634,608.38 2.758 $78.04 $17.94 2.183 $52.14 $9.48 89.11% 13.83%Gastroenterology $1,235,437.78 4.251 $38.27 $13.56 3.745 $36.16 $11.29 20.13% 26.73%Endocrinology $1,228,447.90 6.170 $26.22 $13.48 4.684 $22.42 $8.75 54.05% 6.31%Preventive and Administrative Care $1,219,519.81 2.666 $60.24 $13.38 2.824 $56.01 $13.18 1.50% 10.58%Otolaryngology $1,023,744.86 2.530 $53.29 $11.23 2.926 $38.80 $9.46 18.72% -1.40%Gynecology $933,326.41 4.914 $25.01 $10.24 3.924 $22.75 $7.44 37.67% 21.18%Dermatology $902,698.03 1.886 $63.01 $9.91 1.780 $52.57 $7.80 27.06% 6.79%Ophthalmology $796,070.07 1.465 $71.56 $8.74 1.433 $56.04 $6.69 30.52% 19.56%Neurology $759,152.97 2.417 $41.36 $8.33 2.312 $36.11 $6.96 19.77% -1.42%Obstetrics $718,725.83 1.825 $51.85 $7.89 1.957 $47.72 $7.78 1.35% 8.83%Pulmonology $454,462.93 0.985 $60.73 $4.99 1.067 $44.18 $3.93 27.01% 3.53%Urology $386,761.52 1.537 $33.13 $4.24 1.383 $29.15 $3.36 26.34% 22.90%Isolated Signs/Symptoms $314,271.67 0.949 $43.62 $3.45 0.960 $38.43 $3.07 12.15% 3.60%Hepatology $251,701.36 1.045 $31.70 $2.76 0.723 $27.82 $1.68 64.77% 14.05%Other $212,137.14 0.739 $37.77 $2.33 1.183 $21.60 $2.13 9.30% -17.96%Nephrology $137,577.22 0.826 $21.92 $1.51 0.387 $30.55 $0.99 53.11% 9.42%Hematology $124,696.71 2.104 $7.80 $1.37 0.772 $15.04 $0.97 41.47% -8.05%Chemical dependency $122,733.78 0.256 $63.20 $1.35 0.288 $38.04 $0.91 47.65% -8.78%Neonatology $114,268.93 0.088 $171.06 $1.25 0.145 $112.41 $1.36 -7.66% 7.76%Infectious diseases $97,371.44 0.172 $74.39 $1.07 0.773 $28.10 $1.81 -41.01% -7.76%Late effects/Complications $65,572.86 0.200 $43.25 $0.72 0.201 $29.22 $0.49 47.30% 50.00%Total $19,894,723 58.954 $44.44 $218.31 54.112 $36.95 $166.62 31.02% 11.04%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 4 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Professional Utilization by Major Practice Category
Major Practice Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid PerUnit PMPM
Variancein PMPM
Orthopedic and Arthritic Conditions $3,102,315.39 10.750 $38.02 $34.06 10.321 $31.27 $26.90 26.62%Psychiatry $1,738,283.00 2.793 $81.98 $19.08 2.739 $57.78 $13.19 44.68%Cancer $1,465,128.52 4.603 $41.93 $16.08 5.225 $34.75 $15.13 6.29%Cardiology $1,435,884.91 2.378 $79.55 $15.76 2.206 $49.34 $9.07 73.79%Endocrinology $1,154,916.97 5.963 $25.52 $12.68 4.833 $21.50 $8.66 46.40%Preventive and Administrative Care $1,102,379.28 2.513 $57.80 $12.10 4.518 $37.61 $14.16 -14.53%Otolaryngology $1,037,773.49 3.131 $43.67 $11.39 2.956 $37.88 $9.33 22.09%Gastroenterology $974,546.10 2.565 $50.06 $10.70 2.923 $41.96 $10.22 4.66%Dermatology $845,467.34 1.760 $63.29 $9.28 1.686 $48.02 $6.75 37.56%Gynecology $770,013.48 4.272 $23.74 $8.45 2.187 $26.75 $4.88 73.36%Neurology $769,457.60 2.327 $43.57 $8.45 2.364 $32.15 $6.33 33.35%Ophthalmology $665,512.27 1.239 $70.77 $7.31 1.467 $52.22 $6.38 14.46%Obstetrics $660,490.92 1.744 $49.89 $7.25 1.892 $47.89 $7.55 -3.96%Pulmonology $439,432.67 1.032 $56.11 $4.82 1.076 $41.99 $3.76 28.13%Urology $314,668.55 1.380 $30.04 $3.45 1.296 $28.95 $3.13 10.46%Isolated Signs/Symptoms $302,917.23 0.981 $40.69 $3.33 0.982 $39.57 $3.24 2.68%Other $258,721.50 1.339 $25.46 $2.84 1.145 $20.75 $1.98 43.48%Hepatology $220,085.80 1.028 $28.21 $2.42 0.702 $26.44 $1.55 56.14%Hematology $135,905.43 1.487 $12.04 $1.49 0.636 $18.00 $0.95 56.30%Chemical dependency $135,253.44 0.445 $40.06 $1.48 0.323 $39.11 $1.05 41.02%Nephrology $125,267.40 1.679 $9.83 $1.38 0.366 $27.93 $0.85 61.56%Neonatology $105,843.79 0.071 $196.37 $1.16 0.138 $97.90 $1.12 3.39%Infectious diseases $105,300.16 0.443 $31.30 $1.16 0.857 $19.87 $1.42 -18.50%Late effects/Complications $43,443.71 0.158 $36.11 $0.48 0.198 $26.60 $0.44 8.43%Total $17,909,009 56.077 $42.07 $196.60 53.037 $35.76 $158.05 24.39%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 5 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Prior Aggregate
Report Period: 2/1/2017 12:00:00 ARun Date: 02/17/2017
© Copyright 2017 HealthPartners110_Ex_Professional_by_MPCReport Id: 43735
Page 6 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional Utilization by Service Category
Service Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid perUnit PMPM
Variance inPMPM
PMPMTREND
Office Visit $4,252,744 3.457 $161.97 $46.67 3.086 $120.72 $31.05 50.31% 8.94%
Surgery $3,897,323 18.709 $27.43 $42.77 17.781 $24.87 $36.84 16.07% 10.40%
Radiology / Lab / Pathology $3,637,518 11.007 $43.52 $39.91 8.766 $38.20 $27.91 43.04% 22.35%
Injections / Immunizations / IV Therapy $2,692,177 16.350 $21.68 $29.54 14.801 $16.14 $19.91 48.40% 11.68%
Hospital / Institutional Visits $1,074,584 0.511 $277.10 $11.79 0.511 $222.61 $9.48 24.36% 9.88%
Other Visits / Procedures $1,064,533 1.902 $73.71 $11.68 1.877 $55.70 $8.71 34.09% 11.98%
Mental Health $952,127 1.847 $67.90 $10.45 1.725 $56.43 $8.11 28.78% 0.97%
Physical Exam $801,627 0.509 $207.19 $8.80 0.531 $205.17 $9.08 -3.07% 2.56%
Physical Therapy / Chiropractic $483,054 2.653 $23.97 $5.30 2.949 $21.51 $5.29 0.29% 6.85%
Maternity Care and Delivery $374,089 0.067 $732.07 $4.10 0.054 $961.86 $4.36 -5.88% 9.63%
Routine Eye Care $320,026 0.343 $122.90 $3.51 0.334 $103.75 $2.89 21.55% 3.54%
Allergy / Dermatology $137,320 0.848 $21.31 $1.51 0.716 $17.22 $1.03 46.53% 0.67%
Chemotherapy $93,673 0.046 $267.64 $1.03 0.048 $177.49 $0.71 45.29% 11.96%
Consults $46,683 0.048 $127.55 $0.51 0.036 $144.85 $0.43 18.47% -8.93%
Supplies $35,626 0.563 $8.33 $0.39 0.731 $5.49 $0.33 16.89% -2.50%
E-Visits $19,416 0.064 $40.12 $0.21 0.078 $51.58 $0.33 -36.26% 10.53%
Chemical Health $12,206 0.030 $53.77 $0.13 0.087 $22.62 $0.16 -18.73% -40.91%
Total $19,894,723 58.954 $44.44 $218.31 54.112 $36.95 $166.62 31.02% 11.04%
All Packages/All Sites YTD Qtrly
AggregateCurrent Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
120_Ex_Professional_by_CategoryReport Id: 43735
Page 7 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Professional Utilization by Service Category
Service Category ClaimsUnits perMember
Paid perUnit PMPM
Units perMember
Paid perUnit PMPM
Variance inPMPM
Office Visit $3,902,310 3.437 $149.57 $42.84 3.072 $115.87 $29.66 44.41%
Surgery $3,528,643 16.751 $27.75 $38.74 17.486 $23.72 $34.57 12.06%
Radiology / Lab / Pathology $2,971,193 10.216 $38.31 $32.62 8.365 $39.46 $27.51 18.57%
Injections / Immunizations / IV Therapy $2,409,125 16.384 $19.37 $26.45 14.600 $15.61 $18.99 39.24%
Hospital / Institutional Visits $977,685 0.508 $253.68 $10.73 0.500 $205.06 $8.55 25.54%
Other Visits / Procedures $949,705 1.906 $65.64 $10.43 1.831 $53.28 $8.13 28.23%
Mental Health $943,232 1.635 $76.01 $10.35 1.732 $49.86 $7.20 43.90%
Physical Exam $781,186 0.482 $213.32 $8.58 0.506 $205.48 $8.66 -1.01%
Physical Therapy / Chiropractic $451,625 2.559 $23.24 $4.96 2.826 $21.03 $4.95 0.09%
Maternity Care and Delivery $340,251 0.048 $929.65 $3.74 0.052 $934.22 $4.09 -8.60%
Routine Eye Care $308,786 0.335 $121.52 $3.39 0.335 $102.50 $2.86 18.40%
Allergy / Dermatology $136,746 0.957 $18.81 $1.50 0.679 $16.58 $0.94 60.05%
Chemotherapy $83,423 0.045 $243.22 $0.92 0.048 $180.99 $0.72 27.72%
Consults $51,120 0.049 $138.54 $0.56 0.032 $154.92 $0.42 34.77%
Supplies $36,499 0.631 $7.62 $0.40 0.824 $4.78 $0.33 21.97%
Chemical Health $20,225 0.079 $33.93 $0.22 0.089 $22.75 $0.17 31.80%
E-Visits $17,256 0.055 $41.18 $0.19 0.059 $62.48 $0.31 -38.18%
Total $17,909,009 56.077 $42.07 $196.60 53.037 $35.76 $158.05 24.39%
All Packages/All Sites YTD Qtrly
AggregatePrior Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
120_Ex_Professional_by_CategoryReport Id: 43735
Page 8 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Professional PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
120_Ex_Professional_by_Report Id: 43735
Page 9 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Inpatient Utilization by Major Practice Category
Major Practice Category ClaimsAdmits
per 1000Paid per
AdmitDays
per 1000 PMPMAdmits per
1000Paid Per
AdmitDays
per 1000 PMPMVariancein PMPM
PMPMTrend
Orthopedic and Arthritic Conditions $1,673,183 9.1 $24,249 33.2 $18.36 7.9 $21,023 34.9 $13.87 32.41% 79.47%Cardiology $1,277,000 4.5 $37,559 17.8 $14.01 4.8 $27,763 23.1 $11.05 26.81% 62.34%Neurology $874,402 3.7 $31,229 24.6 $9.59 3.5 $31,238 28.9 $9.18 4.47% -34.32%Obstetrics $819,661 12.5 $8,628 36.9 $8.99 13.6 $7,472 34.3 $8.45 6.41% 43.84%Endocrinology $741,634 3.3 $29,665 16.2 $8.14 2.7 $26,078 13.4 $5.84 39.44% 70.65%Gastroenterology $587,002 4.7 $16,306 16.5 $6.44 3.5 $14,629 13.4 $4.25 51.58% 77.90%Neonatology $437,502 9.7 $5,912 28.2 $4.80 11.1 $5,397 30.4 $5.00 -4.07% 23.71%Cancer $434,009 2.1 $27,126 6.6 $4.76 3.3 $27,983 17.3 $7.75 -38.54% 1.71%Pulmonology $347,398 2.8 $16,543 15.9 $3.81 2.8 $19,061 12.9 $4.47 -14.81% 147.40%Psychiatry $242,824 2.5 $12,780 14.2 $2.66 4.1 $13,332 37.3 $4.56 -41.61% -41.54%Hepatology $206,603 2.6 $10,330 8.4 $2.27 1.0 $18,183 3.8 $1.48 53.58% -53.58%Chemical dependency $186,151 2.9 $8,461 29.0 $2.04 2.3 $12,465 32.0 $2.34 -12.75% -42.54%Urology $179,370 1.1 $22,421 3.7 $1.97 0.8 $14,058 2.6 $0.90 118.54% 198.48%Infectious diseases $132,368 0.8 $22,061 3.0 $1.45 1.3 $15,407 6.4 $1.70 -14.75% 245.24%Gynecology $124,409 1.2 $13,823 2.2 $1.37 0.7 $14,383 1.7 $0.88 54.50% 61.18%Nephrology $86,181 1.2 $9,576 4.1 $0.95 0.8 $32,235 5.7 $2.11 -55.13% -73.76%Late effects/Complications $60,685 0.5 $15,171 2.5 $0.67 0.6 $16,129 2.0 $0.84 -20.94% -8.22%Otolaryngology $34,364 0.3 $17,182 0.8 $0.38 0.7 $18,407 2.7 $1.01 -62.65% -56.82%Dermatology $28,085 0.3 $14,042 0.8 $0.31 0.6 $10,505 3.0 $0.49 -36.93% 82.35%Other $14,707 0.1 $14,707 0.4 $0.16 0.1 $34,732 0.9 $0.21 -24.37% 0.00%Ophthalmology $9,718 0.1 $9,718 0.1 $0.11 0.1 $11,449 0.2 $0.07 51.62% -90.35%Hematology $9,069 0.1 $9,069 0.4 $0.10 0.5 $16,356 1.9 $0.63 -84.24% -95.82%Isolated Signs/Symptoms $0 0.0 $0 0.0 $0.00 0.0 $13,307 0.1 $0.04 -100.00% -100.00%Preventive and Administrative Care $0 0.0 $0 0.0 $0.00 0.5 $25,214 2.8 $1.02 -100.00% -100.00%Total $8,506,323 66.1 $16,945 265.5 $93.34 67.2 $15,752 311.8 $88.15 5.89% 13.59%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 10 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Inpatient Utilization by Major Practice Category
Major Practice Category ClaimsAdmits
per 1000Paid per
AdmitDays
per 1000 PMPMAdmits per
1000Paid Per
AdmitDays
per 1000 PMPMVariancein PMPM
Neurology $1,330,120 4.9 $35,949 44.3 $14.60 3.8 $24,855 28.5 $7.86 85.89%Orthopedic and Arthritic Conditions $931,938 7.0 $17,584 27.8 $10.23 8.2 $20,228 37.5 $13.75 -25.62%Cardiology $785,963 5.8 $17,863 19.9 $8.63 5.1 $23,618 24.4 $9.98 -13.58%Obstetrics $569,673 11.3 $6,624 25.8 $6.25 13.1 $6,843 32.7 $7.47 -16.26%Hepatology $445,188 1.3 $44,519 6.6 $4.89 0.9 $20,610 3.9 $1.53 219.00%Endocrinology $434,545 4.3 $13,168 9.5 $4.77 3.0 $21,002 15.4 $5.26 -9.28%Cancer $425,955 3.2 $17,748 15.1 $4.68 3.8 $26,301 17.8 $8.26 -43.42%Psychiatry $414,071 5.9 $9,202 63.9 $4.55 4.7 $11,685 47.8 $4.53 0.24%Neonatology $353,246 7.9 $5,887 21.1 $3.88 10.4 $5,605 29.3 $4.86 -20.28%Nephrology $329,929 2.0 $21,995 7.2 $3.62 0.6 $22,788 3.8 $1.23 195.36%Gastroenterology $329,822 3.2 $13,743 9.4 $3.62 3.5 $14,316 12.4 $4.18 -13.34%Chemical dependency $323,594 4.6 $9,246 39.0 $3.55 2.3 $10,653 29.3 $2.05 72.87%Hematology $217,615 0.8 $36,269 5.5 $2.39 0.4 $28,463 2.8 $1.01 135.96%Pulmonology $140,027 1.7 $10,771 3.7 $1.54 2.6 $14,089 11.5 $3.10 -50.46%Ophthalmology $103,393 0.0 $0 3.2 $1.14 0.1 $64,042 1.0 $0.32 253.31%Otolaryngology $79,726 0.5 $19,932 1.6 $0.88 0.6 $14,215 2.0 $0.71 22.74%Gynecology $77,668 1.1 $9,708 2.1 $0.85 1.1 $12,876 2.5 $1.17 -27.40%Late effects/Complications $66,298 0.8 $11,050 1.3 $0.73 0.6 $13,464 2.0 $0.63 15.08%Urology $60,275 0.8 $10,046 1.4 $0.66 1.1 $11,764 3.6 $1.07 -38.02%Infectious diseases $38,669 0.5 $9,667 1.6 $0.42 1.3 $16,533 6.4 $1.79 -76.34%Dermatology $15,508 0.1 $15,508 0.5 $0.17 0.4 $13,756 1.8 $0.43 -60.09%Isolated Signs/Symptoms $6,285 0.1 $6,285 0.4 $0.07 0.0 $8,558 0.1 $0.02 253.58%Preventive and Administrative Care $5,427 0.3 $2,713 0.8 $0.06 0.6 $21,696 4.5 $1.04 -94.27%Other $0 0.0 $0 0.0 $0.00 0.0 $34,280 0.3 $0.13 -100.00%Total $7,484,934 68.1 $14,478 311.7 $82.17 68.1 $14,516 321.1 $82.40 -0.28%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 11 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Top 10 Inpatient PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Current Aggregate
Report Period: 2/1/2017 12:00:00 ARun Date: 02/17/2017
© Copyright 2017 HealthPartners130_Ex_Inpatient_by_MPCReport Id: 43735
Page 12 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Inpatient Utilization by Service Category
Service Category ClaimsAdmits
per 1000Paid Per
AdmitDays per
1000 PMPMAdmits per
1000Paid per
AdmitDays per
1000 PMPMVariancein PMPM
PMPMTrend
Surgical $4,787,321 19.5 $32,347 74.1 $52.53 16.0 $31,569 61.0 $42.07 24.86% 37.19%
Medical $1,600,847 16.3 $12,910 58.7 $17.57 17.5 $13,841 63.8 $20.20 -13.04% -3.51%
Maternity $837,155 12.9 $8,542 38.4 $9.19 13.5 $7,434 34.5 $8.38 9.66% 27.99%
Newborn $445,243 9.7 $6,017 27.8 $4.89 11.3 $6,787 34.0 $6.39 -23.52% -29.34%
Other Treatments $423,252 0.9 $60,465 5.0 $4.64 0.6 $52,508 2.9 $2.65 75.28% 1,756.00%
Chemical Health $169,640 2.5 $8,928 27.9 $1.86 2.4 $14,608 42.5 $2.93 -36.46% -48.90%
Mental Health $121,582 2.0 $8,105 7.2 $1.33 3.1 $11,866 20.9 $3.04 -56.05% -49.81%
Non-Acute $121,283 2.2 $7,134 26.2 $1.33 2.7 $10,907 52.1 $2.50 -46.73% -73.51%
Total $8,506,323 66.1 $16,945 265.5 $93.34 67.2 $15,752 311.8 $88.15 5.89% 13.59%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Current Year Actual
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
140_Ex_Inpatient_By_CategoryReport Id: 43735
Page 13 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Inpatient Utilization by Service Category
Service Category ClaimsAdmits
per 1000Paid Per
AdmitDays per
1000 PMPMAdmits per
1000Paid per
AdmitDays per
1000 PMPMVariancein PMPM
Surgical $3,487,649 15.9 $28,824 53.5 $38.29 16.7 $27,697 61.4 $38.44 -0.39%
Medical $1,658,952 18.8 $11,601 60.6 $18.21 18.3 $13,091 67.0 $20.02 -9.02%
Maternity $653,913 12.5 $6,883 30.8 $7.18 13.3 $6,885 33.5 $7.64 -6.03%
Newborn $630,491 8.0 $10,336 28.2 $6.92 10.6 $7,136 33.3 $6.30 9.80%
Non-Acute $457,306 4.1 $14,752 43.5 $5.02 2.7 $10,410 52.4 $2.38 110.65%
Chemical Health $331,702 3.4 $12,758 77.7 $3.64 2.4 $13,723 49.7 $2.74 32.84%
Mental Health $241,834 5.0 $6,364 17.1 $2.65 3.7 $9,651 21.6 $2.94 -9.83%
Other Treatments $23,088 0.3 $11,544 0.3 $0.25 0.4 $58,261 2.2 $1.94 -86.93%
Total $7,484,934 68.1 $14,478 311.7 $82.17 68.1 $14,516 321.1 $82.40 -0.28%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Prior Year Actual
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
140_Ex_Inpatient_By_CategoryReport Id: 43735
Page 14 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Inpatient PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
140_Ex_Inpatient_By_CateReport Id: 43735
Page 15 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient Utilization by Major Practice Category
Major Practice Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid Per
Unit PMPMVariancein PMPM
PMPMTrend
Cancer $1,690,627 5,025 $44.30 $18.55 5,501 $32.77 $15.02 23.51% -1.90%Orthopedic and Arthritic Conditions $1,624,817 3,378 $63.34 $17.83 3,154 $63.00 $16.56 7.69% -11.73%Cardiology $1,284,583 3,187 $53.07 $14.10 3,101 $48.99 $12.66 11.35% 3.68%Gastroenterology $642,815 1,749 $48.40 $7.05 2,170 $49.87 $9.02 -21.79% 15.01%Endocrinology $567,954 2,572 $29.08 $6.23 1,604 $37.35 $4.99 24.81% 6.50%Psychiatry $492,073 960 $67.49 $5.40 761 $77.20 $4.90 10.22% -3.23%Gynecology $485,021 1,161 $55.03 $5.32 829 $57.08 $3.94 35.00% 77.33%Nephrology $484,807 5,066 $12.60 $5.32 1,614 $17.72 $2.38 123.23% 40.37%Chemical dependency $396,133 894 $58.33 $4.35 571 $55.75 $2.65 63.82% -32.03%Otolaryngology $361,213 692 $68.71 $3.96 934 $64.74 $5.04 -21.36% -12.00%Neurology $334,921 896 $49.22 $3.68 1,370 $42.42 $4.84 -24.11% -19.65%Pulmonology $266,957 999 $35.20 $2.93 833 $41.35 $2.87 2.03% -2.98%Preventive and Administrative Care $238,441 451 $69.56 $2.62 408 $69.10 $2.35 11.50% 95.52%Urology $218,937 639 $45.09 $2.40 691 $47.74 $2.75 -12.63% 25.65%Ophthalmology $200,469 419 $62.94 $2.20 371 $64.40 $1.99 10.46% 24.29%Dermatology $141,863 443 $42.16 $1.56 473 $51.06 $2.01 -22.62% -7.14%Obstetrics $90,706 165 $72.28 $1.00 237 $71.68 $1.42 -29.81% 28.21%Hepatology $89,725 554 $21.32 $0.98 337 $42.26 $1.19 -17.13% -26.87%Isolated Signs/Symptoms $85,608 163 $69.26 $0.94 230 $66.82 $1.28 -26.53% -22.95%Hematology $85,259 779 $14.42 $0.94 787 $18.60 $1.22 -23.37% -1.05%Infectious diseases $36,891 111 $43.71 $0.40 133 $50.25 $0.56 -27.50% -18.37%Late effects/Complications $31,526 66 $62.93 $0.35 97 $42.71 $0.35 -0.10% -22.22%Neonatology $20,006 43 $60.81 $0.22 161 $34.28 $0.46 -52.16% -37.14%Other $1,833 1 $261.88 $0.02 2 $87.48 $0.02 19.92% -77.78%Total $9,873,188 30,415 $42.74 $108.34 26,371 $45.72 $100.47 7.84% 0.39%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregateCurrent Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 16 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Outpatient Utilization by Major Practice Category
Major Practice Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid Per
Unit PMPMVariancein PMPM
Orthopedic and Arthritic Conditions $1,839,802 3,156 $76.78 $20.20 3,006 $63.02 $15.79 27.94%Cancer $1,722,414 5,863 $38.70 $18.91 5,566 $31.96 $14.83 27.53%Cardiology $1,239,270 2,844 $57.41 $13.60 2,803 $51.32 $11.99 13.50%Chemical dependency $583,304 720 $106.70 $6.40 546 $60.50 $2.75 132.69%Gastroenterology $558,521 1,468 $50.11 $6.13 2,362 $45.06 $8.87 -30.85%Endocrinology $533,317 3,553 $19.78 $5.85 1,351 $36.13 $4.07 43.89%Psychiatry $508,117 635 $105.42 $5.58 706 $78.76 $4.63 20.37%Neurology $417,013 754 $72.83 $4.58 1,522 $41.01 $5.20 -12.00%Otolaryngology $409,652 910 $59.28 $4.50 939 $63.49 $4.97 -9.47%Nephrology $344,953 3,062 $14.84 $3.79 2,018 $11.56 $1.94 94.87%Pulmonology $275,320 729 $49.72 $3.02 640 $45.88 $2.45 23.44%Gynecology $272,901 802 $44.85 $3.00 850 $48.55 $3.44 -12.90%Urology $173,856 601 $38.09 $1.91 695 $43.92 $2.55 -25.01%Ophthalmology $161,370 290 $73.25 $1.77 480 $53.19 $2.13 -16.74%Dermatology $153,112 343 $58.75 $1.68 547 $39.82 $1.82 -7.44%Hepatology $122,494 490 $32.96 $1.34 549 $32.84 $1.50 -10.53%Preventive and Administrative Care $122,476 232 $69.63 $1.34 609 $58.07 $2.95 -54.39%Isolated Signs/Symptoms $110,845 156 $93.54 $1.22 144 $91.55 $1.10 10.55%Hematology $86,313 813 $13.99 $0.95 1,006 $13.72 $1.15 -17.60%Obstetrics $70,931 172 $54.31 $0.78 386 $43.37 $1.39 -44.12%Infectious diseases $44,247 105 $55.73 $0.49 188 $31.02 $0.49 -0.31%Late effects/Complications $40,593 63 $84.39 $0.45 65 $56.53 $0.30 46.15%Neonatology $31,545 32 $128.75 $0.35 151 $25.06 $0.31 10.04%Other $8,447 6 $191.97 $0.09 11 $32.62 $0.03 209.38%Total $9,830,810 27,800 $46.59 $107.92 27,141 $42.73 $96.64 11.67%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
AggregatePrior Year Actual
Report Period: 2/1/2017 12:00:00 AMRun Date: 02/17/2017
© Copyright 2017 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 17 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient PMPM by Major Practice Category
All Packages/All Sites YTD Qtrly
C Current Year P Prior YearC Current Aggregate P Prior Aggregate
Report Period: 2/1/2017 12:00:00 ARun Date: 02/17/2017
© Copyright 2017 HealthPartners150_EX_Outpatient_by_MPCReport Id: 43735
Page 18 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient Utilization by Service Category
Service Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid per
Unit PMPMVariance in
PMPMPMPMTrend
Surgery $3,764,480 8,941 $55.44 $41.31 8,287 $61.13 $42.21 -2.15% -1.97%
Other Treatments $2,050,536 10,851 $24.88 $22.50 8,499 $26.60 $18.84 19.42% 0.90%
Emergency Room $1,392,672 4,061 $45.16 $15.28 3,904 $43.37 $14.11 8.31% 7.00%
Radiology $1,248,459 3,932 $41.81 $13.70 3,099 $43.97 $11.35 20.65% 1.93%
Cardiovascular $491,058 99 $650.41 $5.39 90 $517.12 $3.88 38.75% 25.93%
Physical Therapy / Chiropractic $242,006 512 $62.18 $2.66 614 $67.69 $3.47 -23.37% -3.27%
Lab $206,004 696 $38.97 $2.26 728 $42.41 $2.57 -12.11% 4.15%
Mental Health $179,430 73 $325.64 $1.97 78 $303.49 $1.97 -0.02% -44.51%
Chemical Health $138,124 243 $74.90 $1.52 196 $75.43 $1.23 23.08% -25.49%
Observation/Non-Invasive Procedures $122,170 231 $69.53 $1.34 113 $53.81 $0.51 163.99% 67.50%
Pharmacy, Hospital or Clinic $38,249 775 $6.50 $0.42 763 $4.99 $0.32 32.23% 162.50%
Total $9,873,188 30,415 $42.74 $108.34 26,371 $45.72 $100.47 7.84% 0.39%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Current Year Actual
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
160_Ex_Outpatient_by_CategoryReport Id: 43735
Page 19 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Outpatient Utilization by Service Category
Service Category ClaimsUnits per
1000Paid per
Unit PMPMUnits per
1000Paid per
Unit PMPMVariance in
PMPM
Surgery $3,838,787 8,191 $61.74 $42.14 8,699 $56.24 $40.77 3.38%
Other Treatments $2,031,032 9,868 $27.11 $22.30 8,764 $23.52 $17.18 29.79%
Emergency Room $1,301,171 3,811 $44.98 $14.28 4,051 $39.90 $13.47 6.05%
Radiology $1,224,598 3,249 $49.66 $13.44 2,978 $46.84 $11.62 15.66%
Cardiovascular $389,530 115 $447.22 $4.28 95 $489.64 $3.89 9.92%
Mental Health $323,804 107 $398.28 $3.55 87 $278.96 $2.01 76.56%
Physical Therapy / Chiropractic $250,657 510 $64.77 $2.75 626 $67.67 $3.53 -22.10%
Lab $197,695 716 $36.38 $2.17 700 $37.50 $2.19 -0.84%
Chemical Health $185,791 203 $120.80 $2.04 184 $82.10 $1.26 61.89%
Observation/Non-Invasive Procedures $73,162 121 $79.61 $0.80 123 $40.42 $0.42 93.11%
Pharmacy, Hospital or Clinic $14,584 909 $2.11 $0.16 833 $4.40 $0.31 -47.60%
Total $9,830,810 27,800 $46.59 $107.92 27,141 $42.73 $96.64 11.67%
All Packages/All Sites YTD Qtrly
Aggregate
Note: Claims do not include IBNR
Prior Year Actual
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
160_Ex_Outpatient_by_CategoryReport Id: 43735
Page 20 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Outpatient PMPM by Service Category
All Packages/All Sites YTD Qtrly
CG Current Year PG Prior YearC Current Aggregate PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
160_Ex_Outpatient_by_CatReport Id: 43735
Page 21 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Trend Report
Group Actual Current YearMeasure Prior Year Current Year %Change Prior Year Current Year VarianceTotal Pharmacy PMPM (PL+ML) $105.44 $106.94 1.42% $84.25 $86.63 23.45%Rx Paid PMPM (Plan Paid) $93.35 $95.27 2.06% $73.80 $76.54 24.47%Total Pharmacy (PL+ML) $9,604,456 $9,745,424 1.47% Total Prescriptions 30 day Rx 120,267 118,962 -1.09% Total Members w/Rx benefit 7,591 7,594 0.04% Average Ingredient Cost/Rx $76.41 $78.36 2.54% $69.54 $72.09 8.69%Average Generic Ingredient Cost/Rx $25.70 $25.91 0.81% $23.46 $22.60 14.64%Average Brand Ingredient Cost/Rx $491.33 $548.22 11.58% $429.41 $490.76 11.71%Average Brand Ingredient Cost/Rx(Without Specialty Drugs) $297.45 $320.78 7.84% $262.78 $287.31 11.65%
Average Brand Ingredient Cost/Rx(Specialty Drugs only) $4,645.96 $4,626.26 -0.42% $4,362.16 $4,697.29 -1.51%
Average Rx/Member/Year 15.84 15.66 -1.13% 13.99 13.89 12.80%Average Days Supply/Rx 26.52 26.48 -0.14% 26.23 26.25 0.86%Copay as Percent of Total Pharmacy 11.46% 10.91% -4.81% 12.41% 11.64% -6.28%Average Generic Copay/Rx $6.53 $6.35 -2.71% $6.12 $5.89 7.89%Average Brand Copay/Rx $30.63 $32.11 4.83% $31.16 $32.63 -1.62%% Generic Use 89.11% 89.96% 0.95% 88.65% 89.43% 0.59%% Non-Formulary 2.56% 2.34% -8.71% 3.56% 3.24% -27.78%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Aggregate
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners178_Ex_Pharmacy_TrendReport Id: 43735
Page 22 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic Class
Current Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
PMPMTrend
MS Agents 23.17% $1,324,418 $14.53 $5,383.81 0.03 11.75% $6.34 $5,291.19 0.01 129.27% 18.13%Chronic Inflammatory Disease 70.31% $1,079,502 $11.85 $1,169.56 0.12 70.84% $11.10 $1,206.14 0.11 6.70% 51.34%Diabetes 64.36% $968,679 $10.63 $144.41 0.88 59.68% $8.90 $153.45 0.70 19.44% 7.48%Stimulants 87.33% $583,303 $6.40 $189.51 0.41 83.72% $4.95 $173.78 0.34 29.28% 5.79%Antivirals 64.94% $541,942 $5.95 $452.37 0.16 80.28% $2.50 $242.62 0.12 138.23% 21.18%Oncology 93.71% $453,205 $4.97 $950.12 0.06 89.76% $5.29 $1,064.58 0.06 -6.03% 19.18%OTHER 92.84% $448,833 $4.93 $62.02 0.95 92.09% $3.55 $52.51 0.81 38.58% 3.35%Asthma 32.13% $420,623 $4.62 $99.44 0.56 32.41% $4.28 $104.52 0.49 7.74% -3.95%Dermatology 94.00% $327,035 $3.59 $111.46 0.39 92.38% $3.36 $117.83 0.34 6.83% -3.75%Anticonvulsants 92.15% $178,201 $1.96 $48.57 0.48 91.51% $1.65 $54.06 0.37 18.43% -10.09%Antidepressants 98.08% $144,744 $1.59 $10.37 1.84 98.19% $1.83 $12.81 1.71 -13.11% -30.87%Contraceptives 94.61% $141,653 $1.55 $27.94 0.67 93.40% $1.92 $28.06 0.82 -18.93% -7.19%Pulmonary Hypertension 87.50% $141,426 $1.55 $736.59 0.03 95.96% $0.46 $284.94 0.02 238.63% 118.31%Inflammatory Bowel 4.71% $137,895 $1.51 $811.15 0.02 9.82% $1.19 $699.92 0.02 26.87% 19.84%Cholesterol 94.72% $132,999 $1.46 $15.02 1.17 94.48% $1.51 $17.08 1.06 -3.22% -26.63%Ophthalmics 69.48% $116,994 $1.28 $72.71 0.21 71.27% $1.24 $65.15 0.23 3.83% -9.22%Antipsychotics 91.98% $116,694 $1.28 $111.35 0.14 90.02% $1.19 $145.01 0.10 7.43% -52.06%Ulcer/GERD 97.47% $113,975 $1.25 $21.67 0.69 96.82% $0.61 $13.31 0.55 105.41% 30.21%Hepatitis 71.88% $112,486 $1.23 $3,515.20 0.00 56.65% $1.63 $11,651.46 0.00 -24.44% -77.14%Narcotic Analgesics 95.64% $112,282 $1.23 $32.40 0.46 95.28% $0.85 $28.32 0.36 45.35% -9.56%HRT 63.09% $103,900 $1.14 $58.73 0.23 59.02% $1.09 $62.56 0.21 4.55% -10.94%Antibiotics 99.71% $94,865 $1.04 $16.42 0.76 99.64% $0.97 $15.28 0.76 7.81% -20.61%Anticoagulants 76.02% $94,608 $1.04 $113.44 0.11 77.65% $0.94 $95.72 0.12 9.93% 22.35%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic ClassCurrent Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
PMPMTrend
Hypertension/Cardiac 99.70% $84,162 $0.92 $3.81 2.91 99.28% $1.00 $4.86 2.46 -7.23% -14.81%Osteoporosis 91.24% $73,038 $0.80 $164.13 0.06 96.99% $0.24 $61.22 0.05 240.83% 15.94%Migraines 89.88% $68,958 $0.76 $95.64 0.09 91.94% $0.64 $81.90 0.09 17.45% -17.39%Androgens 55.25% $67,999 $0.75 $375.68 0.02 55.93% $0.49 $315.57 0.02 52.85% 10.29%Cystic Fibrosis 0.00% $66,631 $0.73 $1,448.50 0.01 6.07% $1.49 $3,663.44 0.00 -50.86% 17.74%Smoking Cessation 53.82% $56,391 $0.62 $165.86 0.04 48.35% $0.35 $181.61 0.02 76.52% 29.17%Erectile Dysfunction 0.00% $54,639 $0.60 $260.19 0.03 0.00% $0.51 $163.02 0.04 16.58% 1.69%Over Active Bladder 86.68% $45,295 $0.50 $92.82 0.06 80.04% $0.43 $104.98 0.05 16.19% -19.35%Immunosuppressants 91.34% $37,028 $0.41 $133.68 0.04 86.84% $0.52 $166.51 0.04 -21.98% -8.89%Antiplatelets 82.06% $27,937 $0.31 $66.83 0.06 87.10% $0.18 $44.84 0.05 66.43% 3.33%Colony Stimulating Factors 0.00% $26,581 $0.29 $4,430.17 0.00 0.00% $0.26 $3,328.81 0.00 10.32% 61.11%Growth Hormones 0.00% $25,815 $0.28 $1,843.92 0.00 0.00% $0.99 $3,006.40 0.00 -71.42% 33.33%Allergy 97.97% $25,447 $0.28 $9.06 0.37 96.70% $0.30 $11.32 0.32 -6.70% -56.25%NSAIDS/COX-2 98.77% $24,281 $0.27 $15.67 0.20 99.66% $0.19 $13.52 0.17 41.61% -28.95%Infertility 40.63% $18,386 $0.20 $287.28 0.01 38.96% $0.37 $422.80 0.01 -44.93% -23.08%Antifungals 98.51% $17,646 $0.19 $32.80 0.07 99.66% $0.10 $21.55 0.06 87.27% -13.64%Thyroid 90.88% $17,237 $0.19 $3.47 0.65 87.87% $0.32 $6.09 0.62 -40.08% -5.00%Biliary Cirrhosis 100.00% $13,224 $0.15 $330.61 0.01 100.00% $0.08 $283.89 0.00 90.91% -40.00%Hypnotics 98.67% $12,152 $0.13 $11.53 0.14 97.80% $0.16 $17.62 0.11 -17.82% 0.00%Corticosteroids 99.11% $10,329 $0.11 $7.69 0.18 99.36% $0.26 $18.58 0.17 -57.18% -69.44%Parkinsons Disease 99.02% $8,108 $0.09 $19.83 0.05 97.08% $0.16 $35.22 0.05 -44.50% -40.00%Antianxiety 99.82% $5,964 $0.07 $2.75 0.29 99.73% $0.08 $4.45 0.23 -22.06% 0.00%Alzheimers Disease 100.00% $4,425 $0.05 $83.50 0.01 95.79% $0.04 $33.46 0.01 31.89% -16.67%
Total 179.07% $8,681,936 $95.27 $72.98 1.31 178.08% $76.51 $66.12 13.89 24.51% 2.06%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 24 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Utilization by Therapeutic Class
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
SPECIALTY 14.61% $3,389,709 $37.20 $4,586.89 0.10 7.83% $28.02 $4,576.01 0.07 32.74% 16.80%
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 25 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Pharmacy Utilization by Therapeutic Class
Prior Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
MS Agents 14.03% $1,120,506 $12.30 $5,070.16 0.029 5.01% $5.74 $4,962.49 0.014 114.21%Diabetes 64.71% $900,857 $9.89 $136.80 0.867 60.83% $7.95 $140.14 0.681 24.36%Chronic Inflammatory Disease 74.08% $712,897 $7.83 $901.26 0.104 0.00% $0.00 $0.00 0.000 0.00%Stimulants 82.70% $550,858 $6.05 $188.01 0.386 82.50% $4.79 $179.59 0.320 26.32%Hepatitis 52.73% $490,163 $5.38 $8,912.06 0.007 49.66% $2.05 $11,284.80 0.002 162.06%Antivirals 71.11% $447,647 $4.91 $374.91 0.157 75.64% $2.18 $206.30 0.127 124.93%Asthma 28.17% $438,390 $4.81 $102.81 0.562 32.18% $4.14 $99.85 0.498 16.12%OTHER 92.66% $434,571 $4.77 $59.85 0.957 89.47% $3.72 $72.90 0.612 28.23%Oncology 90.45% $380,173 $4.17 $955.21 0.052 93.10% $5.22 $651.21 0.096 -20.03%Dermatology 93.09% $339,952 $3.73 $115.79 0.387 91.24% $3.11 $116.30 0.320 20.18%Antipsychotics 84.83% $243,483 $2.67 $225.24 0.142 79.44% $1.92 $239.60 0.096 39.55%Antidepressants 97.82% $209,826 $2.30 $15.05 1.837 98.19% $2.27 $16.49 1.653 1.39%Anticonvulsants 90.76% $198,761 $2.18 $55.17 0.475 90.74% $1.66 $55.21 0.361 31.30%Cholesterol 92.22% $181,114 $1.99 $19.30 1.236 93.18% $1.74 $18.81 1.111 14.20%Contraceptives 92.84% $152,280 $1.67 $31.13 0.644 92.68% $2.00 $30.10 0.799 -16.56%Ophthalmics 63.55% $128,199 $1.41 $77.89 0.217 66.88% $1.21 $66.35 0.219 15.99%Narcotic Analgesics 95.87% $123,660 $1.36 $31.76 0.513 94.90% $1.06 $31.33 0.405 28.35%Antibiotics 99.49% $119,050 $1.31 $20.09 0.781 99.57% $1.36 $21.06 0.778 -4.24%HRT 62.58% $116,393 $1.28 $60.00 0.256 54.31% $1.01 $57.75 0.210 26.20%Inflammatory Bowel 4.12% $115,103 $1.26 $677.08 0.022 28.56% $1.47 $609.23 0.029 -14.06%Hypertension/Cardiac 99.46% $97,942 $1.08 $4.45 2.901 99.14% $1.10 $5.28 2.506 -2.57%Ulcer/GERD 96.58% $87,009 $0.96 $15.81 0.725 95.92% $0.61 $13.30 0.552 56.16%Migraines 88.75% $83,873 $0.92 $94.35 0.117 91.71% $0.66 $80.92 0.098 39.90%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 26 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Pharmacy Utilization by Therapeutic ClassPrior Year Actual Aggregate
Therapeutic ClassPercentGeneric Paid PMPM
Paid perRx
Rx perMember
PercentGeneric
PaidPMPM
Paid perRx
Rx perMember
Variancein PMPM
Anticoagulants 79.97% $77,757 $0.85 $109.67 0.093 83.73% $0.77 $83.21 0.111 10.42%Pulmonary Hypertension 33.33% $64,855 $0.71 $3,603.06 0.002 52.33% $0.22 $2,095.31 0.001 217.03%Osteoporosis 89.08% $63,279 $0.69 $157.02 0.053 95.21% $0.22 $49.02 0.054 212.72%Androgens 54.34% $62,282 $0.68 $360.01 0.023 49.44% $0.52 $334.12 0.019 32.41%Allergy 93.48% $57,938 $0.64 $19.57 0.390 90.97% $0.59 $20.74 0.340 8.38%Cystic Fibrosis 0.00% $56,881 $0.62 $1,458.48 0.005 1.50% $0.73 $2,193.77 0.004 -14.46%Over Active Bladder 82.92% $56,142 $0.62 $116.96 0.063 77.99% $0.47 $109.44 0.052 30.28%Erectile Dysfunction 0.00% $53,620 $0.59 $200.08 0.035 0.00% $0.71 $129.09 0.066 -17.42%Smoking Cessation 48.38% $43,739 $0.48 $157.90 0.036 48.79% $0.30 $160.89 0.022 60.50%Immunosuppressants 88.81% $41,131 $0.45 $143.81 0.038 85.36% $0.59 $181.66 0.039 -22.86%NSAIDS/COX-2 99.03% $34,665 $0.38 $21.05 0.217 97.62% $0.33 $22.80 0.175 14.40%Corticosteroids 98.62% $32,659 $0.36 $23.68 0.182 99.35% $0.32 $22.19 0.172 12.42%Antiplatelets 80.91% $27,372 $0.30 $62.21 0.058 88.71% $0.15 $35.64 0.051 99.51%Infertility 41.67% $23,546 $0.26 $245.27 0.013 43.61% $0.21 $276.03 0.009 20.70%Biliary Cirrhosis 100.00% $22,838 $0.25 $340.87 0.009 94.97% $0.12 $15.48 0.095 105.50%Antifungals 100.00% $19,936 $0.22 $32.21 0.082 99.49% $0.16 $33.54 0.057 37.92%Growth Hormones 0.00% $19,319 $0.21 $1,609.93 0.002 0.00% $0.70 $3,034.76 0.003 -69.77%Thyroid 91.34% $18,617 $0.20 $3.63 0.675 87.95% $0.34 $6.46 0.628 -39.54%Colony Stimulating Factors 0.00% $16,477 $0.18 $5,492.38 0.000 0.00% $0.36 $3,774.57 0.001 -49.07%Parkinsons Disease 97.36% $14,052 $0.15 $30.95 0.060 97.29% $0.16 $33.09 0.057 -1.22%Hypnotics 99.47% $12,210 $0.13 $10.76 0.150 97.68% $0.19 $19.18 0.120 -29.91%Antianxiety 100.00% $6,113 $0.07 $2.90 0.278 99.68% $0.10 $5.56 0.222 -34.80%Alzheimers Disease 72.22% $5,284 $0.06 $146.78 0.005 74.65% $0.08 $71.23 0.013 -24.72%
Total 179.07% $8,503,421 $93.35 $70.70 15.843 178.08% $65.34 $56.82 13.798 42.87%
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 27 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Pharmacy Utilization by Therapeutic Class
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
SPECIALTY 9.74% $2,901,118 $31.85 $4,483.95 0.085 6.47% $24.03 $4,179.19 0.069 32.51%
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 28 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 10 Pharmacy PMPM by Therapeutic Class
All Packages/All Sites YTD Qtrly
C P Prior YearCurrent Year C Current Aggregate P Prior Aggregate
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners179_Ex_Pharmacy_by_ClassReport Id: 43735
Page 29 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Channel Management
All Packages/All Sites YTD Qtrly
Utilization and Trend Aggregate
Percent Total Rx Prior Year Current Year % Change Prior Year Current YearCurrent Year
Variance
% Retail 42.50% 41.30% -2.82% 43.66% 42.62% -3.10%
% Extended Retail, 3-month Rx 55.05% 56.45% 2.53% 54.57% 55.73% 1.28%
% Mail Order 1.91% 1.63% -14.53% 1.28% 1.12% 46.10%
% Specialty 0.54% 0.62% 15.47% 0.49% 0.53% 17.40%
Utilization and Trend
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735179_Ex_Pharmacy_by_Class
Page 30 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Channel Management
Prior Year Actual Aggregate
Chain Name % Total Rx Total Rx % Paid Paid % Total Rx % PaidVariance in
% PaidCVS PHARMACARE SPECIALTY PHARM 0.45% 547 30.75% $2,614,432 0.40% 27.77% 10.71%
WALGREENS 33.56% 40,359 23.33% $1,983,595 29.76% 22.41% 4.11%
HEALTHPARTNERS MAILORDER 13.35% 16,061 9.33% $793,262 9.47% 7.56% 23.47%
HEALTHPARTNERS 9.55% 11,490 7.16% $609,235 5.58% 4.47% 60.45%
TARGET 13.64% 16,408 7.15% $607,588 14.25% 8.20% -12.88%
Total 70.56% 84,865 77.71% $6,608,111 59.46% 70.40% 10.38%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Current Year Actual Aggregate
Chain Name % Total Rx Total Rx % Paid Paid % Total Rx % PaidVariance in
% PaidPaid
TrendCVS PHARMACARE SPECIALTY PHARM 0.53% 627 34.08% $2,958,925 0.40% 29.05% 17.32% 10.83%
WALGREENS 33.78% 40,187 21.91% $1,902,409 30.60% 21.11% 3.78% -6.09%
HEALTHPARTNERS MAILORDER 12.56% 14,941 8.48% $736,383 8.88% 6.88% 23.25% -9.11%
HEALTHPARTNERS 9.25% 11,003 7.02% $609,400 5.42% 4.57% 53.58% -1.96%
TARGET 12.85% 15,285 5.90% $512,293 13.65% 7.90% -25.28% -17.48%
Total 68.97% 82,043 77.40% $6,719,410 58.95% 69.51% 10.86% -23.81%
Top 5 Pharmacy Chains
Report Period: 2/1/2017 12:00:00 Run Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735179_Ex_Pharmacy_by_Class
Page 31 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Top 20 Drugs by Cost
Drug Therapeutic Brand / Rx Claims Paid / RxName Class Generic Prior Current %Change Prior Current %Change Prior Current %ChangeHumira* Chronic Inflammatory DisBrand 124 140 12.90% $422,691 $602,565 42.55% $3,408.80 $4,304.03 26.26%Humalog Diabetes Brand 680 669 -1.62% $298,198 $323,298 8.42% $438.53 $483.26 10.20%Enbrel* Chronic Inflammatory DisBrand 48 80 66.67% $164,130 $308,477 87.95% $3,419.37 $3,855.97 12.77%Rebif* MS Agents Brand 42 50 19.05% $229,948 $305,781 32.98% $5,474.95 $6,115.62 11.70%Adderall Stimulants Generic 861 964 11.96% $227,464 $259,259 13.98% $264.19 $268.94 1.80%Lantus Diabetes Brand 827 836 1.09% $246,668 $232,207 -5.86% $298.27 $277.76 -6.88%Copaxone* MS Agents Brand 54 40 -25.93% $302,568 $230,625 -23.78% $5,603.11 $5,765.62 2.90%Glatopa* MS Agents Generic 31 57 83.87% $122,330 $223,093 82.37% $3,946.14 $3,913.91 -0.82%Gilenya* MS Agents Brand 33 33 0.00% $184,270 $220,534 19.68% $5,583.93 $6,682.85 19.68%Advair Asthma Brand 709 580 -18.19% $209,094 $193,638 -7.39% $294.91 $333.86 13.21%Tecfidera* MS Agents Brand 24 26 8.33% $132,318 $160,290 21.14% $5,513.24 $6,165.02 11.82%Imatinib* Oncology Generic 5 or Under 22 0.00% $0 $155,575 0.00% $0.00 $7,071.60 0.00%Victoza Diabetes Brand 189 249 31.75% $102,104 $148,653 45.59% $540.23 $597.00 10.51%Methylphenidate Stimulants Generic 793 843 6.31% $121,042 $139,735 15.44% $152.64 $165.76 8.60%Xyrem* OTHER Brand 13 12 -7.69% $120,084 $121,218 0.94% $9,237.23 $10,101.51 9.36%Truvada Antivirals Brand 5 or Under 83 0.00% $0 $119,500 0.00% $0.00 $1,439.76 0.00%Atripla Antivirals Brand 42 47 11.90% $94,453 $114,640 21.37% $2,248.88 $2,439.15 8.46%Letairis* Pulmonary Hypertension Brand 5 or Under 12 0.00% $0 $104,155 0.00% $0.00 $8,679.57 0.00%Aubagio* MS Agents Brand 5 or Under 17 0.00% $0 $98,981 0.00% $0.00 $5,822.41 0.00%Ibrance* Oncology Brand 5 or Under 11 0.00% $0 $94,364 0.00% $0.00 $8,578.52 0.00%
Total 4,470 4,771 6.73% $2,977,362 $4,156,588 39.61% $666.08 $871.22 30.80%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR* Specialty Drug
Report Period: 2/1/2017 12:Run Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735180_Ex_Pharmacy_Top_20
Page 32 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Pharmacy Top 20 Drugs by Volume
Drug Therapeutic Brand / Rx Claims Paid / RxName Class Generic Prior Current %Change Prior Current %Change Prior Current %ChangeLevothyroxine Thyroid Generic 4,636 4,452 -3.97% $13,835 $12,815 -7.37% $2.98 $2.88 -3.36%Atorvastatin Cholesterol Generic 4,238 4,333 2.24% $7,248 $1,926 -73.43% $1.71 $0.44 -74.27%Lisinopril Hypertension/Cardiac Generic 4,303 4,251 -1.21% $902 $501 -44.44% $0.21 $0.12 -42.86%Omeprazole Ulcer/GERD Generic 3,514 3,165 -9.93% $2,584 $1,137 -56.00% $0.74 $0.36 -51.35%Metformin Diabetes Generic 2,887 2,998 3.84% $2,296 $1,966 -14.39% $0.80 $0.66 -17.50%Simvastatin Cholesterol Generic 3,004 2,576 -14.25% $572 $239 -58.15% $0.19 $0.09 -52.63%Amlodipine Hypertension/Cardiac Generic 2,390 2,575 7.74% $331 $254 -23.30% $0.14 $0.10 -28.57%Sertraline Antidepressants Generic 2,311 2,344 1.43% $1,863 $687 -63.09% $0.81 $0.29 -64.20%Hydrochlorothiazide Hypertension/Cardiac Generic 2,603 2,335 -10.30% $362 $170 -52.98% $0.14 $0.07 -50.00%Metoprolol Hypertension/Cardiac Generic 2,345 2,301 -1.88% $15,251 $9,417 -38.25% $6.50 $4.09 -37.08%Bupropion Antidepressants Generic 1,911 1,951 2.09% $45,954 $20,562 -55.25% $24.05 $10.54 -56.17%Fluticasone Allergy Generic 1,885 1,849 -1.91% $5,300 $1,785 -66.33% $2.81 $0.97 -65.48%Atenolol Hypertension/Cardiac Generic 1,908 1,810 -5.14% $216 $205 -4.79% $0.11 $0.11 0.00%Fluoxetine Antidepressants Generic 1,865 1,760 -5.63% $9,882 $1,524 -84.58% $5.30 $0.87 -83.58%Citalopram Antidepressants Generic 1,639 1,728 5.43% $272 $204 -24.88% $0.17 $0.12 -29.41%Trazodone Antidepressants Generic 1,730 1,543 -10.81% $1,275 $1,111 -12.86% $0.74 $0.72 -2.70%Losartan Hypertension/Cardiac Generic 1,365 1,538 12.67% $648 $421 -35.00% $0.47 $0.27 -42.55%Lisinopril-Hctz Hypertension/Cardiac Generic 1,458 1,372 -5.90% $245 $146 -40.36% $0.17 $0.11 -35.29%Ventolin Asthma Brand 1,372 1,342 -2.19% $25,190 $33,425 32.69% $18.36 $24.91 35.68%Gabapentin Anticonvulsants Generic 5 or Under 1,313 0.00% $0 $4,915 0.00% $0.00 $3.74 0.00%
Total 47,364 47,536 0.36% $134,224 $93,412 -30.41% $2.83 $1.97 -30.66%
All Packages/All Sites YTD Qtrly
Note: Claims do not include IBNR
Report Period: 2/1/2017 12:Run Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735180_Ex_Pharmacy_Top_20
Page 33 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Tier Utilization
Utilization Category Tier 1 Tier 2 Tier 3 Out of Network Total
Professional 17,171,776.47 3,923,909.71 0 189,071.57 $21,284,758
Hospital IP 3,975,670.28 5,101,403.86 0 90,154.95 $9,167,229
Hospital OP 6,419,771.21 3,894,143.78 0 248,430.13 $10,562,345
Pharmacy 9,298,655.22 0 0 0 $9,298,655
DME, Transportation, Other 995,947.46 128,875.77 0 10,525.8 $1,135,349
Preventive/Accidental Dental 0 0 0 0 $0
Total 37,861,820.64 13,048,333.12 0 538,182.46 $51,448,336
Percent of Claims 73.59% 25.36% 0.00% 1.05% 100.00%
Members 7,437 2,634 0 223 10,294
Percent Members 72.25% 25.59% 0.00% 2.17% 100.00%
All Packages/All Sites YTD Qtrly
Notes: Members will be counted more than once if they incurred services in multiple networks.Members with only out-of-network claims = 0Claims include IBNRSome benefit plans do not utilize all tier levles. In these cases, there would be no claims dollars.
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
190_Ex_Tier_Network_UtilizationReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Tier Utilization
Utilization Category Tier 1 Tier 2 Tier 3 Out of Network Total
Professional 15,097,247.83 3,655,457.32 0 211,168.9 $18,963,874
Hospital IP 3,709,688.29 3,896,223.06 0 270,202.52 $7,876,114
Hospital OP 5,768,018.17 3,970,657.73 0 678,526.63 $10,417,203
Pharmacy 7,381,759.73 1,637,393.48 0 0 $9,019,153
DME, Transportation, Other 831,381.43 129,533.01 0 16,218.6 $977,133
Preventive/Accidental Dental 0 0 0 0 $0
Total 32,788,095.44 13,289,264.6 0 1,176,116.65 $47,253,477
Percent of Claims 69.39% 28.12% 0.00% 2.49% 100.00%
Members 7,364 4,930 0 227 12,521
Percent Members 58.81% 39.37% 0.00% 1.81% 100.00%
All Packages/All Sites YTD Qtrly
Notes: Members will be counted more than once if they incurred services in multiple networks.Members with only out-of-network claims = 0Claims include IBNRSome benefit plans do not utilize all tier levels. In these cases, there would be no claims dollars.
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
190_Ex_Tier_Network_UtilizationReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Monthly Summary - Contracts
All Packages/All Sites YTD Qtrly
Member and contract counts are as of the 15th of each month and include retroactive adjustments.
Period Members Total Single Family
Jan 2016 7,572 3,740 2,273 1,467
Feb 2016 7,559 3,737 2,272 1,465
Mar 2016 7,595 3,749 2,276 1,473
Apr 2016 7,610 3,767 2,295 1,472
May 2016 7,595 3,762 2,297 1,465
Jun 2016 7,626 3,768 2,297 1,471
Jul 2016 7,576 3,750 2,289 1,461
Aug 2016 7,581 3,758 2,300 1,458
Sep 2016 7,590 3,760 2,300 1,460
Oct 2016 7,616 3,751 2,281 1,470
Nov 2016 7,611 3,754 2,290 1,464
Dec 2016 7,601 3,742 2,276 1,466
Total 91,132 45,038 27,446 17,592
Average 7,594 3,753 2,287 1,466
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Monthly Summary - Contracts
All Packages/All Sites YTD Qtrly
Member and contract counts are as of the 15th of each month and include retroactive adjustments.
Period Members Total Single Family
Jan 2015 7,612 3,776 2,293 1,483
Feb 2015 7,593 3,770 2,292 1,478
Mar 2015 7,589 3,771 2,298 1,473
Apr 2015 7,623 3,790 2,314 1,476
May 2015 7,609 3,782 2,310 1,472
Jun 2015 7,593 3,769 2,298 1,471
Jul 2015 7,588 3,754 2,284 1,470
Aug 2015 7,622 3,751 2,274 1,477
Sep 2015 7,577 3,737 2,268 1,469
Oct 2015 7,557 3,732 2,268 1,464
Nov 2015 7,564 3,736 2,271 1,465
Dec 2015 7,566 3,732 2,263 1,469
Total 91,093 45,100 27,433 17,667
Average 7,591 3,758 2,286 1,472
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
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Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Monthly Summary - Revenue and Claims
All Packages/All Sites YTD Qtrly
Revenue is shown on an earned premium basis and includes retroactive adjustments. Revenue only includes medical premiums;special charges are not included.
Period Members Total PMPM Total PMPM Care Ratio
Jan 2016 7,572 $4,488,443 $592.77 $3,541,703 $467.74
Feb 2016 7,559 $4,481,907 $592.92 $4,239,044 $560.79
Mar 2016 7,595 $4,496,974 $592.10 $4,380,492 $576.76
Apr 2016 7,610 $4,510,417 $592.70 $4,573,015 $600.92
May 2016 7,595 $4,500,083 $592.51 $5,201,060 $684.80
Jun 2016 7,626 $4,512,336 $591.70 $4,369,435 $572.97
Jul 2016 7,576 $4,486,043 $592.14 $4,531,363 $598.12
Aug 2016 7,581 $4,490,452 $592.33 $4,468,789 $589.47
Sep 2016 7,590 $4,494,219 $592.12 $4,223,935 $556.51
Oct 2016 7,616 $4,498,828 $590.71 $4,081,577 $535.92
Nov 2016 7,611 $4,492,269 $590.23 $4,264,854 $560.35
Dec 2016 7,601 $4,485,762 $590.15 $5,690,375 $748.64
Total 91,132 $53,937,731 $53,565,640 99.31%
Average 7,594 $4,494,811 $591.87 $4,463,803 $587.78
Claims include IBNR and pooling charges
Revenue ClaimsCurrent Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 38 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Monthly Summary - Revenue and Claims
All Packages/All Sites YTD Qtrly
Revenue is shown on an earned premium basis and includes retroactive adjustments. Revenue only includes medical premiums;special charges are not included.
Period Members Total PMPM Total PMPM Care Ratio
Jan 2015 7,612 $4,382,113 $575.68 $3,797,656 $498.90
Feb 2015 7,593 $4,373,323 $575.97 $3,412,764 $449.46
Mar 2015 7,589 $4,370,339 $575.88 $4,066,332 $535.82
Apr 2015 7,623 $4,384,641 $575.19 $4,412,285 $578.81
May 2015 7,609 $4,376,122 $575.12 $3,747,879 $492.56
Jun 2015 7,593 $4,364,128 $574.76 $4,445,837 $585.52
Jul 2015 7,588 $4,352,489 $573.60 $4,076,387 $537.21
Aug 2015 7,622 $4,356,819 $571.61 $3,872,488 $508.07
Sep 2015 7,577 $4,337,716 $572.48 $4,468,647 $589.76
Oct 2015 7,557 $4,328,635 $572.80 $3,925,901 $519.51
Nov 2015 7,564 $4,334,346 $573.02 $4,257,483 $562.86
Dec 2015 7,566 $4,335,515 $573.03 $4,295,997 $567.80
Total 91,093 $52,296,184 $48,779,655 93.28%
Average 7,591 $4,358,015 $574.10 $4,064,971 $535.49
Claims include IBNR and pooling charges
Revenue ClaimsPrior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners
200_Ex_Monthly_SummaryReport Id: 43735
Page 39 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Contract Distribution
All Packages/All Sites YTD Qtrly
C PCurrent Year Prior Year
Average Members per Ramsey County [12900] Prior Year Aggregate
All Family Type Contracts: 3.62 3.60 3.42
All Contracts: 2.02 2.02 2.04
C Current Aggregate P Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 AM © Copyright 2017 HealthPartners Report Id: 43735
200_Ex_Monthly_Summary
Page 40 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Demographics Summary
Member Months Average % of Total Aggregate % of Total
Female 50,376 4,198 55.28% 53.54%
Male 40,756 3,396 44.72% 46.46%
Total 91,132 7,594 100.00% 100.00%
All Packages/All Sites YTD Qtrly
Current Year Gender Distribution
Current Year Relationship Distribution
Member Months Average % of Total Aggregate % of Total
Policyholder 44,627 3,719 48.97% 48.81%
Dependent 46,505 3,875 51.03% 51.19%
Total 91,132 7,594 100.00% 100.00%
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
210_Ex_Demographics_SummaryReport Id: 43735
Page 41 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Demographics Summary
Member Months Average % of Total Aggregate % of Total
Female 50,378 4,198 55.30% 53.55%
Male 40,715 3,393 44.70% 46.45%
Total 91,093 7,591 100.00% 100.00%
All Packages/All Sites YTD Qtrly
Prior Year Gender Distribution
Prior Year Relationship Distribution
Member Months Average % of Total Aggregate % of Total
Policyholder 44,884 3,740 49.27% 49.20%
Dependent 46,209 3,851 50.73% 50.80%
Total 91,093 7,591 100.00% 100.00%
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
210_Ex_Demographics_SummaryReport Id: 43735
Page 42 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Demographics: Detail
Age RangeFemale
Policyholder DependentMale
Policyholder Dependent Total % of Total
Under 1 0 24 0 42 66 0.87%
1 - 4 0 131 0 172 303 3.99%
5 - 9 0 264 0 228 492 6.47%
10 - 14 0 251 1 267 519 6.83%
15 - 19 2 310 0 307 619 8.14%
20 - 24 9 296 12 267 584 7.68%
25 - 29 100 78 65 51 294 3.87%
30 - 34 195 58 146 36 435 5.72%
35 - 39 261 85 138 85 569 7.49%
40 - 44 226 94 153 88 561 7.38%
45 - 49 268 89 186 77 620 8.16%
50 - 54 319 96 234 89 738 9.71%
55 - 59 369 94 230 103 796 10.47%
60 - 64 423 64 246 107 840 11.05%
65 Over 74 11 46 34 165 2.17%
Total 2,246 1,945 1,457 1,953 7,601 100.00%
All Packages/All Sites YTD Qtrly
Counts shown are for the last month in the reporting period.
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
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Page 43 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Demographics: Detail
Age RangeFemale
Policyholder DependentMale
Policyholder Dependent Total % of Total
Under 1 0 28 0 36 64 0.85%
1 - 4 0 144 0 163 307 4.06%
5 - 9 0 246 1 236 483 6.38%
10 - 14 0 268 0 254 522 6.90%
15 - 19 2 308 0 307 617 8.15%
20 - 24 11 288 13 271 583 7.71%
25 - 29 97 61 64 60 282 3.73%
30 - 34 185 63 126 36 410 5.42%
35 - 39 260 71 143 79 553 7.31%
40 - 44 227 99 148 75 549 7.26%
45 - 49 260 81 184 89 614 8.12%
50 - 54 321 106 229 86 742 9.81%
55 - 59 409 90 226 108 833 11.01%
60 - 64 409 66 276 99 850 11.23%
65 Over 69 10 45 33 157 2.08%
Total 2,250 1,929 1,455 1,932 7,566 100.00%
All Packages/All Sites YTD Qtrly
Counts shown are for the last month in the reporting period.
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
220_Ex_Demographics_DetailReport Id: 43735
Page 44 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Age Distribution
All Packages/All Sites YTD Qtrly
CG Current Year CA Current Aggregate PG Prior Year PA Prior Aggregate
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
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Page 45 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Cost Savings Detail
All Packages/All Sites YTD Qtrly
COB Savings
COB SavingsWorkers Compensation $8,293 $0 $0 $0 $1,364 $0 $9,657No-Fault $922 $0 $6,829 $0 $4,058 $0 $11,809Third Party Liability $0 $0 $0 $0 $0 $0 $0Occupational Health $0 $0 $0 $0 $0 $0 $0Other Insurance: Under 65 $430,705 $542,048 $1,067,327 $0 $25,581 $0 $2,065,662Other Insurance: Over 65 $186,050 $968 $648,993 $0 $10,546 $0 $846,558Total: $625,970 $543,017 $1,723,149 $0 $41,549 $0 $2,933,685
Benefit Design Savings
Benefit Design SavingsDeductibles $223,487 $2,391 $13,868 $0 $10,087 $0 $249,833Copayments/Coinsurance $1,208,578 $82,178 $397,730 $1,063,489 $185,626 $0 $2,937,600Other Member Liability $716 $71 $32,534 $0 $0 $0 $33,322Total: $1,432,781 $84,641 $444,132 $1,063,489 $195,713 $0 $3,220,755
Other Savings
Other SavingsUCR Limits $34,562 $0 $0 $0 $0 $0 $34,562Ineligible Services $42,501 $145 -$18,816 $0 $35,340 $0 $59,170Total: $77,063 $145 -$18,816 $0 $35,340 $0 $93,733
Provider Discount Savings
Provider Discount SavingsNegotiated Discounts $11,769,785 $7,797,704 $13,733,460 $9,335,989 $725,033 $0 $43,361,972Total: $11,769,785 $7,797,704 $13,733,460 $9,335,989 $725,033 $0 $43,361,972
Professional Hospital IP Hospital OP Pharmacy Other Dental TotalBilled Charge $33,460,569 $16,793,596 $25,612,509 $18,972,423 $2,046,691 $0 $96,885,787
Grand Total Savings $13,905,600 $8,425,507 $15,881,925 $10,399,478 $997,635 $0 $49,610,145
Claims$19,894,723 $8,506,323 $9,873,188 $8,681,936 $1,056,178 $0 $48,012,348
(billed charge - grand total savings + tax)
Provider Tax $339,754 $138,235 $142,605 $108,991 $7,122 $0 $736,706
Savings Percentage 41.56% 50.17% 62.01% 54.81% 48.74% 0.00% 51.20%(based on billed charge)
Note: Claims do not include IBNR
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
310_Ex_Cost_Savings_DetailReport Id: 43735
Page 46 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Cost Savings Detail
All Packages/All Sites YTD Qtrly
COB Savings
COB SavingsWorkers Compensation $158 $0 $15,746 $0 $0 $0 $15,904No-Fault $2,406 $0 $270 $0 $0 $0 $2,676Third Party Liability $21 $0 $0 $0 $0 $0 $21Occupational Health $0 $0 $0 $0 $0 $0 $0Other Insurance: Under 65 $456,521 $819,573 $1,025,491 $0 $23,590 $0 $2,325,176Other Insurance: Over 65 $116,808 $19,184 $59,893 $0 $332 $0 $196,216Total: $575,913 $838,757 $1,101,400 $0 $23,922 $0 $2,539,992
Benefit Design Savings
Benefit Design SavingsDeductibles $226,484 $6,297 $15,502 $0 $6,843 $0 $255,126Copayments/Coinsurance $1,128,354 $94,559 $380,720 $1,101,034 $153,456 $0 $2,858,123Other Member Liability $52 $1,755 $4,133 $0 $0 $0 $5,941Total: $1,354,890 $102,611 $400,355 $1,101,034 $160,299 $0 $3,119,190
Other Savings
Other SavingsUCR Limits $84,675 $0 $0 $0 $0 $0 $84,675Ineligible Services $18,486 $5,514 $21 $0 $67,771 $0 $91,792Total: $103,160 $5,514 $21 $0 $67,771 $0 $176,466
Provider Discount Savings
Provider Discount SavingsNegotiated Discounts $10,605,142 $7,206,487 $12,798,069 $8,109,460 $653,160 $0 $39,372,317Total: $10,605,142 $7,206,487 $12,798,069 $8,109,460 $653,160 $0 $39,372,317
Professional Hospital IP Hospital OP Pharmacy Other Dental TotalBilled Charge $30,247,199 $15,520,822 $23,994,444 $17,598,440 $1,820,307 $0 $89,181,211
Grand Total Savings $12,639,106 $8,153,370 $14,299,844 $9,210,494 $905,151 $0 $45,207,965
Claims$17,909,009 $7,484,934 $9,830,810 $8,503,421 $922,237 $0 $44,650,412
(billed charge - grand total savings + tax)
Provider Tax $300,916 $117,483 $136,210 $115,476 $7,082 $0 $677,166
Savings Percentage 41.79% 52.53% 59.60% 52.34% 49.73% 0.00% 50.69%(based on billed charge)
Note: Claims do not include IBNR
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
310_Ex_Cost_Savings_DetailReport Id: 43735
Page 47 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service Categories
Provider Claims ClaimantsHEALTHPARTNERS MEDICAL GROUP $4,809,334 3,695
REGIONS HOSPITAL-RAD/ACUTE/SLEEP $3,418,292 962
CVS/SPECIALTY # $2,958,925 68
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW WEST $1,659,911 175
UNITED HOSPITAL $1,657,168 242
MAYO CLINIC ROCHESTER $1,275,346 93
HEALTHEAST ST JOHNS & MIDWAY $1,071,439 286
MERCY HOSPITAL $800,492 58
MAYO CLINIC HOSPITAL-ROCHESTER $770,237 34
HEALTHPARTNERS MAIL ORDER PHARMACY $736,383 525
MINNESOTA ONCOLOGY HEMATOLOGY, PA $633,004 55
HEALTHEAST WOODWINDS HOSPITAL $609,700 160
ABBOTT NORTHWESTERN HOSPITAL $597,840 123
FAIRVIEW PHARMACY SERVICES LLC-HH $594,346 5 or under
PARK NICOLLET CLINIC $573,868 383
CVS PHARMACY # $552,701 1,321
HEALTHEAST ST JOSEPHS $505,879 80
PARK NICOLLET METHODIST HOSPITAL-ACUTE $469,638 85
FAIRVIEW SOUTHDALE HOSPITAL $443,343 78
CHILDRENS HEALTH CARE-ST PAUL $439,984 186
HEALTHPARTNERS SAME DAY SURG CENTER $422,767 261
SUMMIT ORTHOPEDICS,LTD $366,680 264
TWIN CITIES ANESTHESIA ASSOCIATES PA $328,409 295
All Packages/All Sites YTD Qtrly
Current Year by Dollars Paid
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 48 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service CategoriesProvider Claims ClaimantsLAKEVIEW HOSPITAL $310,539 90
TWIN CITIES ORTHOPEDICS,PA $309,085 196
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 49 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Top 25 Medical Providers - All Service Categories
Provider Claims ClaimantsHEALTHPARTNERS MEDICAL GROUP $4,680,044 3,636
REGIONS HOSPITAL-RAD/ACUTE/SLEEP $3,392,796 1,016
CVS/SPECIALTY # $2,614,432 67
CHILDRENS HEALTH CARE-ST PAUL $1,194,438 175
MAYO CLINIC ROCHESTER $1,189,028 85
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW WEST $1,072,109 174
UNITED HOSPITAL $991,016 207
HEALTHEAST ST JOHNS & MIDWAY $959,240 223
MAYO CLINIC HOSPITAL-ROCHESTER $827,846 34
HEALTHPARTNERS MAIL ORDER PHARMACY $793,262 553
HEALTHEAST ST JOSEPHS $713,294 97
CVS PHARMACY # $654,085 1,367
HENNEPIN COUNTY MEDICAL CENTER $638,608 52
FAIRVIEW PHARMACY SERVICES LLC-HH $554,000 5 or under
ABBOTT NORTHWESTERN HOSPITAL $475,907 132
HEALTHEAST WOODWINDS HOSPITAL $433,403 175
HEALTHPARTNERS SAME DAY SURG CENTER $398,839 248
SUMMIT ORTHOPEDICS,LTD $386,690 289
PARK NICOLLET CLINIC $382,102 329
ST MARYS HOSP-ROCHESTER/TRANSPLANT $337,025 5 or under
MINNESOTA GASTROENTEROLOGY PA $334,963 193
WALGREENS $313,744 628
CREATIVE CARE,INC $313,613 5 or under
All Packages/All Sites YTD Qtrly
Prior Year by Dollars Paid
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 50 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Top 25 Medical Providers - All Service CategoriesProvider Claims ClaimantsPARK NICOLLET METHODIST HOSPITAL-ACUTE $306,932 57
FAIRVIEW SOUTHDALE HOSPITAL $296,569 63
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 51 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service Categories
Provider Claimants ClaimsHEALTHPARTNERS MEDICAL GROUP 3,695 $4,809,334
REGIONS HOSPITAL-RAD/ACUTE/SLEEP 962 $3,418,292
UNITED HOSPITAL 242 $1,657,168
HEALTHEAST ST JOHNS & MIDWAY 286 $1,071,439
HEALTHPARTNERS MAIL ORDER PHARMACY 525 $736,383
PARK NICOLLET CLINIC 383 $573,868
CVS PHARMACY # 1,321 $552,701
HEALTHPARTNERS SAME DAY SURG CENTER 261 $422,767
SUMMIT ORTHOPEDICS,LTD 264 $366,680
TWIN CITIES ANESTHESIA ASSOCIATES PA 295 $328,409
WALGREENS 628 $302,999
CUB PHARMACY 337 $284,458
ST PAUL RADIOLOGY PA 1,344 $275,485
HEALTHPARTNERS MENTAL HEALTH 282 $257,917
EMERGENCY PHYSICIANS,PA 294 $209,920
CVS PHARMACY 532 $203,898
HEALTHPARTNERS MEDICAL GROUP-NW ALLIANCE 247 $186,703
REGIONS HOSPITAL-PRO FEE 339 $176,086
DERMATOLOGY CONSULTANTS,PA 258 $104,489
ST PAUL EYE CLINIC,PA 272 $80,188
FULCRUM HEALTH,INC 505 $79,446
HOSPITAL PATHOLOGY ASSOCIATES 288 $62,512
HEALTHPARTNERS WORKSITE HEALTH 681 $23,155
All Packages/All Sites YTD Qtrly
Current Year by Claimant Count
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 52 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Top 25 Medical Providers - All Service CategoriesProvider Claimants ClaimsVIRTUWELL 258 $16,058
NOT APPLICABLE 334 $12,189
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 53 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Top 25 Medical Providers - All Service Categories
Provider Claimants ClaimsHEALTHPARTNERS MEDICAL GROUP 3,636 $4,680,044
ST PAUL RADIOLOGY PA 1,382 $241,320
CVS PHARMACY # 1,367 $654,085
REGIONS HOSPITAL-RAD/ACUTE/SLEEP 1,016 $3,392,796
HEALTHPARTNERS WORKSITE HEALTH 991 $32,979
WALGREENS 628 $313,744
HEALTHPARTNERS MAIL ORDER PHARMACY 553 $793,262
FULCRUM HEALTH,INC 526 $82,582
CVS PHARMACY 479 $211,505
CUB PHARMACY 350 $269,855
REGIONS HOSPITAL-PRO FEE 346 $163,861
PARK NICOLLET CLINIC 329 $382,102
NOT APPLICABLE 291 $10,232
SUMMIT ORTHOPEDICS,LTD 289 $386,690
HEALTHPARTNERS MENTAL HEALTH 285 $263,198
TARGET CLINIC MINNESOTA 283 $14,173
TWIN CITIES ANESTHESIA ASSOCIATES PA 278 $282,008
EMERGENCY PHYSICIANS,PA 263 $147,101
DERMATOLOGY CONSULTANTS,PA 251 $117,998
HEALTHPARTNERS SAME DAY SURG CENTER 248 $398,839
HEALTHPARTNERS ST. PAUL PHARMACY 247 $112,896
ST PAUL EYE CLINIC,PA 241 $66,604
HEALTHPARTNERS WOODBURY PHARMACY 236 $80,488
All Packages/All Sites YTD Qtrly
Prior Year by Claimant Count
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 54 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Top 25 Medical Providers - All Service CategoriesProvider Claimants ClaimsSUBURBAN RADIOLOGIC CONSULTANTS 235 $39,744
VIRTUWELL 233 $13,462
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners320_Ex_Top_ProvidersReport Id: 43735
Page 55 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Effect of Catastrophic Claims on PMPM
Amount Aggregate Variance PMPM Trend
Total Claims $51,448,336
Total Claims: Per Member Per Month $564.55 $458.40 23.16% 8.83%
Catastrophic Claims Excess Amount $15,470,710 (for members with $25,000 +, the amount over $25,000
Catastrophic Excess Amount: % of Total Claims 30.07% 30.66%
(catastrophic claims as a percentage of total claims)
Net Claims $35,977,626
(total claims less catastrophic excess)
Net Claims: Per Member Per Month $394.79 $317.84 24.21% 7.43%
Note: Catastrophic Dollars do not include IBNR Claims include IBNR
All Packages/All Sites YTD Qtrly
Current Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 A © Copyright 2017 HealthPartners
400_Ex_Effect_Catastrophic_ClaimsReport Id: 43735
Page 56 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Effect of Catastrophic Claims on PMPM
Amount Aggregate Variance
Total Claims $47,253,477
Total Claims: Per Member Per Month $518.74 $435.33 19.16%
Catastrophic Claims Excess Amount $13,777,050 (for members with $25,000 +, the amount over $25,000
Catastrophic Excess Amount: % of Total Claims 29.16% 29.22%
(catastrophic claims as a percentage of total claims)
Net Claims $33,476,427
(total claims less catastrophic excess)
Net Claims: Per Member Per Month $367.50 $308.15 19.26%
Note: Catastrophic Dollars do not include IBNR Claims include IBNR
All Packages/All Sites YTD Qtrly
Prior Year
Run Date: 02/17/2017Report Period: 2/1/2017 12:00:00 A © Copyright 2017 HealthPartners
400_Ex_Effect_Catastrophic_ClaimsReport Id: 43735
Page 57 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical PMPM Before and After Removing Claims in Excess of Catastrophic Threshold
All Packages/All Sites YTD Qtrly
C CCurrent Year Current Aggregate P Prior Year Prior AggregateP
Report Period: 2/1/2017 12:00:00 ARun Date: 02/17/2017
© Copyright 2017 HealthPartners Report Id: 43735400_Ex_Effect_Catastrophic_Claims
Page 58 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Distribution of Claimants and Dollars
Dollar RangeNumber ofClaimants Claims
Cumulative %of Claimants
Cumulative %of Claims
Cumulative %of Claimants
Cumulative %of Claims
1 - 250 960 $107,990 12.75% 0.22% 19.65% 0.35%
250 - 500 753 $279,246 22.74% 0.81% 32.49% 1.27%
500 - 1000 1,161 $844,188 38.16% 2.56% 49.41% 3.65%
1000 - 2500 1,741 $2,861,298 61.27% 8.52% 69.39% 9.89%
2500 - 5000 1,153 $4,081,683 76.58% 17.03% 81.48% 18.15%
5000 - 10000 785 $5,505,076 87.00% 28.49% 89.31% 28.80%
10000 - 15000 317 $3,910,106 91.21% 36.64% 92.82% 37.12%
15000 - 25000 280 $5,402,052 94.93% 47.89% 96.00% 48.95%
25000 - 35000 137 $4,032,976 96.75% 56.29% 97.39% 56.91%
35000 - 50000 96 $3,944,164 98.02% 64.50% 98.36% 64.72%
50000 - 75000 66 $3,840,573 98.90% 72.50% 99.13% 73.66%
75000 - 100000 34 $2,900,994 99.35% 78.54% 99.47% 79.42%
100000 - 125000 17 $1,956,578 99.58% 82.62% 99.65% 83.19%
125000+ 32 $8,345,427 100.00% 100.00% 100.00% 100.00%
7,532 $48,012,348
All Packages/All Sites YTD Qtrly
AggregateCurrent Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
410_Ex_Distribution_of_ClaimantsReport Id: 43735
Page 59 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Distribution of Claimants and Dollars
Dollar RangeNumber ofClaimants Claims
Cumulative %of Claimants
Cumulative %of Claims
Cumulative %of Claimants
Cumulative %of Claims
1 - 250 983 $107,954 13.08% 0.24% 21.08% 0.41%
250 - 500 798 $294,261 23.70% 0.90% 34.35% 1.44%
500 - 1000 1,198 $877,467 39.65% 2.87% 51.34% 4.02%
1000 - 2500 1,740 $2,841,027 62.80% 9.23% 71.06% 10.70%
2500 - 5000 1,152 $4,067,786 78.13% 18.34% 82.55% 19.22%
5000 - 10000 701 $4,903,326 87.46% 29.32% 90.14% 30.42%
10000 - 15000 332 $4,061,936 91.88% 38.42% 93.40% 38.79%
15000 - 25000 262 $5,019,606 95.37% 49.66% 96.32% 50.58%
25000 - 35000 137 $4,026,148 97.19% 58.68% 97.62% 58.57%
35000 - 50000 82 $3,369,975 98.28% 66.22% 98.56% 66.72%
50000 - 75000 59 $3,658,000 99.07% 74.42% 99.24% 75.48%
75000 - 100000 22 $1,862,711 99.36% 78.59% 99.53% 80.73%
100000 - 125000 21 $2,369,845 99.64% 83.90% 99.70% 84.54%
125000+ 27 $7,190,371 100.00% 100.00% 100.00% 100.00%
7,514 $44,650,412
All Packages/All Sites YTD Qtrly
AggregatePrior Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
410_Ex_Distribution_of_ClaimantsReport Id: 43735
Page 60 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Distribution of Member Liability
Member LiabilityDollar Range
Number ofClaimants
MemberLiability Claims
Cumulative %of Claimants
Cumulative % ofMember LIability
Cumulative %of Claims
1 - 250 3,935 $381,175 $4,196,481 52.24% 11.96% 8.74%
250 - 500 1,507 $536,219 $6,257,419 72.25% 28.78% 21.77%
500 - 1000 1,144 $802,424 $9,426,570 87.44% 53.96% 41.41%
1000 - 2500 900 $1,312,105 $25,942,394 99.39% 95.12% 95.44%
2500 - 5000 46 $155,510 $2,189,485 100.00% 100.00% 100.00%
5000 - 10000 0 $0 $0 100.00% 100.00% 100.00%
10000+ 0 $0 $0 100.00% 100.00% 100.00%
Total 7,532 $3,187,434 $48,012,348
All Packages/All Sites YTD Qtrly
Current Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
415_Ex_Distribution_of_Member_LiReport Id: 43735
Page 61 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Distribution of Member Liability
Member LiabilityDollar Range
Number ofClaimants
MemberLiability Claims
Cumulative %of Claimants
Cumulative % ofMember Liability
Cumulative %of Claims
1 - 250 3,976 $388,573 $3,848,421 52.91% 12.48% 8.62%
250 - 500 1,441 $516,337 $5,469,347 72.09% 29.07% 20.87%
500 - 1000 1,165 $823,012 $9,527,654 87.60% 55.50% 42.21%
1000 - 2500 889 $1,234,929 $22,868,655 99.43% 95.17% 93.42%
2500 - 5000 42 $143,738 $2,890,897 99.99% 99.79% 99.90%
5000 - 10000 1 $6,660 $45,439 100.00% 100.00% 100.00%
10000+ 0 $0 $0 100.00% 100.00% 100.00%
Total 7,514 $3,113,249 $44,650,412
All Packages/All Sites YTD Qtrly
Prior Year Actual
Note: Claims do not include IBNR
Run Date: 02/17/2017Report Period: 2/1/2017 12:00: © Copyright 2017 HealthPartners
415_Ex_Distribution_of_Member_LiReport Id: 43735
Page 62 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsDilated Cardiomyopathy $859,471
Fabry (-anderson) Disease $556,880
Secondary Malignant Neoplasm Of Bone $488,978
Laceration Of Liver, Unspecified Degree, Initial Encounter $448,730
Tetralogy Of Fallot $393,461
Malignant Melanoma Of Skin, Unspecified $335,966
Acute Respiratory Failure With Hypoxia $326,481
Sepsis Due To Methicillin Susceptible Staphylococcus Aureus $324,203
End Stage Renal Disease $315,603
Secondary Malignant Neoplasm Of Other Parts Of Nervous System $287,241
Encounter For Antineoplastic Immunotherapy $286,700
Malignant Neoplasm Of Ascending Colon $286,614
Ulcerative Colitis, Unspecified, Without Complications $266,554
Malignant Neoplasm Of Prostate $203,540Pathological Fracture In Neoplastic Disease, Other Specified Site, Initial Encounter ForFracture $200,597
Postsurgical Lordosis $197,035
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 63 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSt Elevation (stemi) Myocardial Infarction Involving Left Anterior Descending CoronaryArtery $194,777
Benign Neoplasm Of Peripheral Nerves And Autonomic Nervous System Of Abdomen $190,962
Malignant Neoplasm Of Brain, Unspecified $185,472Encounter For Adjustment And Management Of Automatic Implantable CardiacDefibrillator $181,971
Stenosis Of Other Cardiac Prosthetic Devices, Implants And Grafts, Initial Encounter $179,583
Sensitive Diagnosis $171,247
Malignant Neoplasm Of Upper-outer Quadrant Of Right Female Breast $167,742
Unspecified Juvenile Rheumatoid Arthritis Of Unspecified Site $163,761
Malignant Neoplasm Of Pancreas, Unspecified $161,727
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $155,088
Primary Osteoarthritis, Left Shoulder $151,697
Sensitive Diagnosis $140,930
Malignant Neoplasm Of Unspecified Part Of Right Bronchus Or Lung $136,666
Idiopathic Acute Pancreatitis $129,773
Spinal Stenosis, Cervical Region $129,425
Spinal Stenosis, Cervical Region $126,554
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 64 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsNonrheumatic Aortic (valve) Stenosis With Insufficiency $124,852
Obstructive Sleep Apnea (adult) (pediatric) $122,886
Malignant Neoplasm Of Central Portion Of Right Female Breast $121,503
Other Secondary Pulmonary Hypertension $121,232
Malignant Melanoma Of Right Lower Limb, Including Hip $120,915
Spondylolisthesis, Lumbar Region $120,492
Malignant Neoplasm Of Lower-outer Quadrant Of Left Female Breast $120,184
End Stage Renal Disease $116,147
Sepsis, Unspecified Organism $115,629
End Stage Renal Disease $115,366
Malignant Neoplasm Of Upper-outer Quadrant Of Left Female Breast $115,155
Myelodysplastic Syndrome, Unspecified $111,632
Chronic Myeloid Leukemia, Bcr/abl-positive, Not Having Achieved Remission $109,347
Neuromuscular Dysfunction Of Bladder, Unspecified $109,140
Sensitive Diagnosis $105,759
Benign Neoplasm Of Cerebral Meninges $103,981
Malignant Neoplasm Of Overlapping Sites Of Left Female Breast $102,356
Multiple Sclerosis $99,482
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 65 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsUrethral Stricture, Unspecified $96,376
Malignant Neoplasm Of Endometrium $95,034
Sensitive Diagnosis $94,977
Chronic Myeloid Leukemia, Bcr/abl-positive, Not Having Achieved Remission $93,883
Malignant Neoplasm Of Unspecified Site Of Unspecified Female Breast $92,906
Spinal Stenosis, Lumbar Region $92,422
Longitudinal Reduction Defect Of Left Femur $89,566
Non-st Elevation (nstemi) Myocardial Infarction $89,009
Rheumatoid Arthritis Without Rheumatoid Factor, Multiple Sites $88,483
Multiple Sclerosis $88,358
Sensitive Diagnosis $88,159
Sensitive Diagnosis $87,973
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $87,480
Multiple Sclerosis $87,447
Other Spondylosis With Radiculopathy, Lumbar Region $87,235
Anemia, Unspecified $87,108
Type 1 Diabetes Mellitus Without Complications $86,448
Malignant Neoplasm Of Prostate $83,803
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 66 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsPain In Left Knee $83,020
Spinal Stenosis, Cervical Region $82,698
Calculus Of Ureter $81,411
Atherosclerosis Of Native Arteries Of Left Leg With Ulceration Of Other Part Of Foot $80,999
Malignant Neoplasm Of Prostate $80,349
Sepsis, Unspecified Organism $80,102
Multiple Sclerosis $79,230
Type 1 Diabetes Mellitus With Hyperglycemia $78,533
Bilateral Primary Osteoarthritis Of Knee $77,990
Neuromuscular Dysfunction Of Bladder, Unspecified $77,900
Encounter For Screening Mammogram For Malignant Neoplasm Of Breast $77,247
Malignant Neoplasm Of Upper Lobe, Right Bronchus Or Lung $76,826
Other Instability, Right Foot $76,510
Abscess Of Lung With Pneumonia $76,397
Endometriosis Of Pelvic Peritoneum $75,632
Spinal Stenosis, Lumbar Region $74,437
Sensitive Diagnosis $72,205
Unspecified Abdominal Pain $72,081
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 67 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsPseudarthrosis After Fusion Or Arthrodesis $71,575
Fistula Of Stomach And Duodenum $70,548
Malignant Neoplasm Of Prostate $69,787
Neuromuscular Dysfunction Of Bladder, Unspecified $69,762
Occlusion And Stenosis Of Left Carotid Artery $69,322
Crohn's Disease Of Small Intestine Without Complications $67,803
Retention Of Urine, Unspecified $66,484
Sensitive Diagnosis $66,345
Unilateral Primary Osteoarthritis, Right Knee $65,542
Malignant Neoplasm Of Endometrium $64,886
Intramural Leiomyoma Of Uterus $64,796
Sensitive Diagnosis $63,285
Encounter For Antineoplastic Radiation Therapy $62,728
Congenital Malformations Of Intestinal Fixation $61,532
Subserosal Leiomyoma Of Uterus $60,620
Sepsis, Unspecified Organism $59,854Pain Due To Internal Orthopedic Prosthetic Devices, Implants And Grafts, InitialEncounter $59,660
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 68 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsAbdominal Aortic Aneurysm, Without Rupture $59,623Pain Due To Internal Orthopedic Prosthetic Devices, Implants And Grafts, InitialEncounter $59,281
Encounter For Screening For Malignant Neoplasm Of Colon $58,526
Other Spondylosis With Radiculopathy, Cervical Region $58,417
Malignant Neoplasm Of Appendix $57,994
Sensitive Diagnosis $57,663
Type 1 Diabetes Mellitus With Ketoacidosis Without Coma $57,560
Diaphragmatic Hernia Without Obstruction Or Gangrene $57,362
Malignant Carcinoid Tumor Of The Bronchus And Lung $57,357
Cleft Palate, Unspecified $57,275
Rheumatoid Arthritis, Unspecified $57,183
Sensitive Diagnosis $57,013
Encounter For Antineoplastic Radiation Therapy $56,604
Unilateral Post-traumatic Osteoarthritis, Right Knee $56,370
Unspecified Hydronephrosis $55,877
Unspecified Iridocyclitis $55,726
Diarrhea, Unspecified $55,642
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 69 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsOsteomyelitis, Unspecified $55,575
Other Pneumothorax $55,544
Malignant Neoplasm Of Frontal Lobe $55,242
Inflammatory Polyarthropathy $54,984
Rheumatoid Arthritis, Unspecified $54,688
Vesicointestinal Fistula $54,384
Sensitive Diagnosis $54,269
Sensitive Diagnosis $54,032
Non-st Elevation (nstemi) Myocardial Infarction $53,636
Complete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $53,482
Infection Following A Procedure, Initial Encounter $53,229
Unilateral Primary Osteoarthritis, Left Hip $53,158
Non-st Elevation (nstemi) Myocardial Infarction $53,005
Multiple Sclerosis $52,852
Juvenile Rheumatoid Polyarthritis (seronegative) $52,740
Radiculopathy, Cervical Region $52,556
Chronic Ethmoidal Sinusitis $52,542
Precocious Puberty $52,532
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 70 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsOsteoarthritis Of Knee, Unspecified $52,490
Cystic Fibrosis, Unspecified $52,037
Plantar Fascial Fibromatosis $52,016Atherosclerotic Heart Disease Of Native Coronary Artery With Other Forms Of AnginaPectoris $51,551
Malignant Neoplasm Of Cervix Uteri, Unspecified $51,320
Sensitive Diagnosis $51,053
Psoriasis Vulgaris $50,925
Gastrostomy Status $50,754
Obstructive Sleep Apnea (adult) (pediatric) $50,670
Sprain Of Anterior Cruciate Ligament Of Left Knee, Initial Encounter $50,366
Calculus Of Gallbladder With Acute Cholecystitis With Obstruction $50,212
Sensitive Diagnosis $49,892
Acute On Chronic Systolic (congestive) Heart Failure $48,854
Malignant Neoplasm Of Unspecified Site Of Left Female Breast $48,639
Acute Serous Otitis Media, Bilateral $48,277
Unilateral Primary Osteoarthritis, Right Hip $48,034
Other Specified Rheumatoid Arthritis, Multiple Sites $47,462
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 71 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsMigraine Without Aura, Intractable, Without Status Migrainosus $47,330
Streptococcus B Carrier State Complicating Childbirth $47,122
Benign Neoplasm Of Pituitary Gland $47,032
Unilateral Primary Osteoarthritis, Right Knee $46,947
Rheumatoid Arthritis With Rheumatoid Factor, Unspecified $46,928
Arthropathic Psoriasis, Unspecified $46,604
Non-st Elevation (nstemi) Myocardial Infarction $46,168
Cerebral Infarction, Unspecified $46,140
Unilateral Primary Osteoarthritis, Right Knee $45,946
Sensitive Diagnosis $45,862
Diaphragmatic Hernia Without Obstruction Or Gangrene $45,768
Other Cervical Disc Degeneration, Mid-cervical Region $45,652
Unilateral Primary Osteoarthritis, Left Knee $45,591
Stenosis Of Other Cardiac Prosthetic Devices, Implants And Grafts, Initial Encounter $45,127
Arthropathic Psoriasis, Unspecified $44,328
Malignant Neoplasm Of Prostate $44,313
Unilateral Primary Osteoarthritis, Right Hip $44,286
Sensitive Diagnosis $44,076
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 72 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $43,897
Calculus Of Kidney $43,861
Primary Pulmonary Hypertension $43,748
Other Cyst Of Bone, Other Site $43,626
Sensitive Diagnosis $43,607
Embolism And Thrombosis Of Arteries Of The Lower Extremities $43,413
Unilateral Primary Osteoarthritis, Left Hip $43,312
Acute Respiratory Failure With Hypoxia $43,311
Edema, Unspecified $43,294
Crohn's Disease Of Small Intestine With Other Complication $43,253
Encounter For Screening For Malignant Neoplasm Of Colon $42,445
Encounter For Antineoplastic Immunotherapy $42,387
Intestinal Adhesions [bands] With Obstruction (postprocedural) (postinfection) $42,345
Pericardial Effusion (noninflammatory) $41,976
Type 1 Diabetes Mellitus With Hyperglycemia $41,970
Other Chronic Pain $41,738
Benign Neoplasm Of Right Ovary $41,538
Lesion Of Plantar Nerve, Right Lower Limb $41,495
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 73 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsGastro-esophageal Laceration-hemorrhage Syndrome $41,403
Sepsis Due To Hemophilus Influenzae $40,922
Osteoarthritis Of Knee, Unspecified $40,764
Other Specified Diabetes Mellitus With Ketoacidosis Without Coma $40,596Strain Of Other Specified Muscles, Fascia And Tendons At Thigh Level, Right Thigh,Initial Encounter $40,567
Benign Neoplasm Of Parathyroid Gland $40,468
Pseudarthrosis After Fusion Or Arthrodesis $40,397
Unspecified Atrial Flutter $40,351
Other Cervical Disc Displacement, Mid-cervical Region $40,101
Family History Of Ischemic Heart Disease And Other Diseases Of The Circulatory System $39,998
Sensitive Diagnosis $39,866
Unilateral Primary Osteoarthritis, Right Knee $39,772
Arthropathic Psoriasis, Unspecified $39,542
Induration Penis Plastica $39,232
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $39,079
Unspecified Fracture Of Lower End Of Right Tibia, Initial Encounter For Closed Fracture $39,059
Sensitive Diagnosis $39,048
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 74 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnspecified Sequelae Of Unspecified Cerebrovascular Disease $38,954
Osteoarthritis Of Knee, Unspecified $38,952
Morbid (severe) Obesity Due To Excess Calories $38,717
Hydronephrosis With Renal And Ureteral Calculous Obstruction $38,714
Sensitive Diagnosis $38,556
Benign Neoplasm, Unspecified Site $38,503
Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris $38,452
Esophageal Varices Without Bleeding $38,247
Unspecified Cataract $38,164
Sensitive Diagnosis $38,116
Malignant Neoplasm Of Endometrium $38,073
Unilateral Primary Osteoarthritis, Right Hip $37,958
Other Internal Derangements Of Left Knee $37,935
Unilateral Primary Osteoarthritis, Right Knee $37,854
Other Cervical Disc Displacement, Mid-cervical Region $37,738
Sensitive Diagnosis $37,724
Infection Following A Procedure, Initial Encounter $37,718
Unilateral Primary Osteoarthritis, Left Knee $37,657
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 75 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther Chest Pain $37,584
Paroxysmal Atrial Fibrillation $37,359
Sensitive Diagnosis $37,256
Dissection Of Other Specified Artery $36,824
Sensitive Diagnosis $36,706
Precocious Puberty $36,671
Other Acute Postprocedural Pain $36,550
Other Specified Types Of Non-hodgkin Lymphoma, Extranodal And Solid Organ Sites $36,434
Unilateral Primary Osteoarthritis, Left Hip $36,220
Excessive And Frequent Menstruation With Irregular Cycle $35,899
Delayed Milestone In Childhood $35,893
Streptococcal Sepsis, Unspecified $35,780
Osteoarthritis Of Knee, Unspecified $35,725
Leiomyoma Of Uterus, Unspecified $35,633
Sensitive Diagnosis $35,471
Type 2 Diabetes Mellitus Without Complications $35,469
Unilateral Primary Osteoarthritis, Left Hip $35,395
Other Secondary Cataract, Left Eye $35,301
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 76 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther Ascites $35,206
Other Specified Disorders Of Eyelid $34,988
Morbid (severe) Obesity Due To Excess Calories $34,928
Excessive And Frequent Menstruation With Irregular Cycle $34,822
End Stage Renal Disease $34,679
Leiomyoma Of Uterus, Unspecified $34,564
Bilateral Primary Osteoarthritis Of Knee $34,549
Unilateral Primary Osteoarthritis, Left Knee $34,464
Poisoning By Propionic Acid Derivatives, Intentional Self-harm, Initial Encounter $34,448
Other Noninflammatory Disorders Of Ovary, Fallopian Tube And Broad Ligament $34,434
Dizziness And Giddiness $34,010
Dry Eye Syndrome Of Bilateral Lacrimal Glands $33,991
Sensitive Diagnosis $33,864
Guillain-barre Syndrome $33,828
Rheumatoid Arthritis With Rheumatoid Factor, Unspecified $33,669
Acute Appendicitis With Generalized Peritonitis $33,646
Malignant Neoplasm Of Thyroid Gland $33,644
Malignant Neoplasm Of Prostate $33,417
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 77 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Therapeutic Drug Level Monitoring $33,408
Unspecified Atrial Fibrillation $33,183
Rheumatoid Arthritis Without Rheumatoid Factor, Multiple Sites $33,106
Sprain Of Anterior Cruciate Ligament Of Right Knee, Initial Encounter $33,040
Unilateral Primary Osteoarthritis, Right Knee $33,004
Sensitive Diagnosis $32,922
Unilateral Primary Osteoarthritis, Right Knee $32,879
Anemia, Unspecified $32,869Displaced Intraarticular Fracture Of Right Calcaneus, Initial Encounter For ClosedFracture $32,769
Unilateral Primary Osteoarthritis, Right Knee $32,620
Unilateral Primary Osteoarthritis, Right Knee $32,548
Intervertebral Disc Disorders With Radiculopathy, Lumbar Region $32,391
Disruptive Mood Dysregulation Disorder $32,292
Displacement Of Intraocular Lens, Initial Encounter $32,203
Unilateral Primary Osteoarthritis, Left Knee $32,145
Osteoarthritis Of Knee, Unspecified $32,106
Chronic Ethmoidal Sinusitis $32,046
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 78 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsInfections Of Kidney In Pregnancy, Third Trimester $32,014
Benign Neoplasm Of Left Ovary $31,995
Sensorineural Hearing Loss, Bilateral $31,850
Unilateral Primary Osteoarthritis, Left Knee $31,780
Other Specified Diseases Of Intestine $31,581
Sensitive Diagnosis $31,578
Ulcerative (chronic) Pancolitis Without Complications $31,494
Vascular Disorder Of Intestine, Unspecified $31,372
Sensitive Diagnosis $31,275
Benign Neoplasm Of Ascending Colon $31,242
Sensitive Diagnosis $31,204
Bilateral Primary Osteoarthritis Of Knee $31,185
Maternal Care For Breech Presentation, Fetus 1 $31,133
Sensitive Diagnosis $30,990
Unilateral Primary Osteoarthritis, Right Knee $30,652
Supraventricular Tachycardia $30,526
Unspecified Lump In Breast $30,219
Unilateral Primary Osteoarthritis, Right Hip $30,195
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 79 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsAtherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $30,162
Unspecified Osteoarthritis, Unspecified Site $30,128
Atypical Atrial Flutter $30,121
Incisional Hernia Without Obstruction Or Gangrene $30,120
Incomplete Rotator Cuff Tear Or Rupture Of Left Shoulder, Not Specified As Traumatic $30,077
Pre-existing Type 2 Diabetes Mellitus, In Childbirth $29,908
Hyperlipidemia, Unspecified $29,895Other Generalized Epilepsy And Epileptic Syndromes, Not Intractable, Without StatusEpilepticus $29,894
Obstructed Labor Due To Breech Presentation, Fetus 1 $29,801
Dermatochalasis Of Right Upper Eyelid $29,750
Sensitive Diagnosis $29,698
Malignant Neoplasm Of Lower-outer Quadrant Of Left Female Breast $29,634
Thrombotic Microangiopathy $29,564
Chronic Or Unspecified Gastrojejunal Ulcer With Hemorrhage $29,490
Bilateral Inguinal Hernia, Without Obstruction Or Gangrene, Not Specified As Recurrent $29,477
Unspecified Abnormalities Of Gait And Mobility $29,309
Morbid (severe) Obesity Due To Excess Calories $29,206
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 80 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Other Preprocedural Examination $29,127
Sensitive Diagnosis $28,995
Primary Osteoarthritis, Left Shoulder $28,968Other Intraarticular Fracture Of Lower End Of Right Radius, Initial Encounter For ClosedFracture $28,963
Sensitive Diagnosis $28,955
Sensitive Diagnosis $28,857
Deviated Nasal Septum $28,815
Sensitive Diagnosis $28,626
Unilateral Primary Osteoarthritis, Right Hip $28,569
Other Abnormal Involuntary Movements $28,558
Unilateral Inguinal Hernia, Without Obstruction Or Gangrene, Not Specified As Recurrent $28,523Displaced Fracture Of Lateral Malleolus Of Left Fibula, Initial Encounter For ClosedFracture $28,349
Respiratory Distress Of Newborn, Unspecified $28,332
Morbid (severe) Obesity Due To Excess Calories $28,208
Hypothyroidism, Unspecified $28,033
Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Left Cerebellar Artery $27,968
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 81 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $27,839
Benign Neoplasm Of Left Ovary $27,831
Right Lower Quadrant Pain $27,612
Sensitive Diagnosis $27,608
Benign Lipomatous Neoplasm Of Intra-abdominal Organs $27,600
Headache $27,503
Unilateral Primary Osteoarthritis, Right Knee $27,442
Neoplasm Of Uncertain Behavior Of Left Ovary $27,268
Unilateral Primary Osteoarthritis, Left Knee $27,221
Ganglion, Right Wrist $27,196
Incomplete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $27,105
Sensitive Diagnosis $27,069
Sensitive Diagnosis $27,048
Sensitive Diagnosis $27,037
Osteoarthritis Of Knee, Unspecified $27,036
Sensitive Diagnosis $26,922
Other Iron Deficiency Anemias $26,826
Calculus Of Ureter $26,814
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 82 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $26,765
Carpal Tunnel Syndrome, Right Upper Limb $26,738
Right Upper Quadrant Pain $26,724
Cervical Shortening, Second Trimester $26,700
Other Specified Diseases Of Gallbladder $26,599
Malignant Neoplasm Of Left Ovary $26,557
Spondylosis Without Myelopathy Or Radiculopathy, Lumbar Region $26,451
Other Specified Diseases Of Gallbladder $26,395
Calculus Of Gallbladder And Bile Duct With Cholecystitis, Unspecified, With Obstruction $26,331
Other Postprocedural Complications And Disorders Of Nervous System $26,297
Urticaria, Unspecified $26,278
Morbid (severe) Obesity Due To Excess Calories $26,231
Ankylosing Spondylitis Of Multiple Sites In Spine $25,984
Persistent Atrial Fibrillation $25,933
Obstructive Sleep Apnea (adult) (pediatric) $25,730
Sensitive Diagnosis $25,714
Unilateral Primary Osteoarthritis, Left Hip $25,702
Sensitive Diagnosis $25,667
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 83 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis ClaimsParkinson's Disease $25,600
Chronic Or Unspecified Duodenal Ulcer With Perforation $25,584
Displaced Fracture Of Shaft Of Left Clavicle, Initial Encounter For Closed Fracture $25,543
Other Spondylosis With Radiculopathy, Lumbar Region $25,537
Precocious Puberty $25,514
Sensitive Diagnosis $25,497
Sensitive Diagnosis $25,410
Lumbago With Sciatica, Right Side $25,401
Sensitive Diagnosis $25,377
Obstructive Sleep Apnea (adult) (pediatric) $25,328
Alcoholic Hepatitis With Ascites $25,210
Hydronephrosis With Renal And Ureteral Calculous Obstruction $25,182Atherosclerotic Heart Disease Of Native Coronary Artery With Unspecified AnginaPectoris $25,094
Calculus Of Kidney With Calculus Of Ureter $25,046
Sensitive Diagnosis $25,031
Unspecified Dislocation Of Right Acromioclavicular Joint, Initial Encounter $25,010
Total $25,020,710
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 84 of 106
Ramsey County [12900]
Paid through 01/31/2017Service Dates of 01/01/2016 through 12/31/2016
Medical Catastrophic Cases
Principal Diagnosis Claims
Total Above $25,000 $15,470,710
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Current Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 85 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsSubarachnoid Hemorrhage $851,373
Lipidoses $558,515
Sensitive Diagnosis $470,687
Malignant Neoplasm Of Upper Lobe, Bronchus Or Lung $408,230
Malignant Neoplasm Of Ascending Colon $347,367
Sensitive Diagnosis $338,684
Acute And Chronic Respiratory Failure $303,079
Sensitive Diagnosis $301,931
Spinal Stenosis In Cervical Region $298,704
Encounter For Antineoplastic Chemotherapy $276,372
Sensitive Diagnosis $262,816
Malignant Melanoma Of Skin, Unspecified $225,468
Polyarticular Juvenile Rheumatoid Arthritis, Chronic Or Unspecified $207,913
Acute Lymphoid Leukemia, Without Mention Of Having Achieved Remission $206,067
Malignant Neoplasm Of Breast (female), Unspecified $201,035
End Stage Renal Disease $187,889
Malignant Neoplasm Of Rectum $187,472
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 86 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Antineoplastic Chemotherapy $179,408
Atrial Fibrillation $171,844
Other Malignant Neoplasm Of Unspecified Site $168,269
Malignant Neoplasm Of Kidney, Except Pelvis $161,081
Malignant Melanoma Of Skin Of Upper Limb, Including Shoulder $159,719
Malignant Neoplasm Of Breast (female), Unspecified $154,779
Anemia Of Other Chronic Disease $147,336
Encounter For Antineoplastic Immunotherapy $143,711
Encounter For Antineoplastic Chemotherapy $137,180
Spondylolisthesis, Congenital $133,443
Iliotibial Band Syndrome, Right Leg $124,234
Sensitive Diagnosis $124,081
Other Mechanical Complication Of Other Internal Orthopedic Device, Implant, And Graft $123,687
Malignant Neoplasm Of Prostate $123,523
Sensitive Diagnosis $120,508
End Stage Renal Disease $118,254
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $117,577
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 87 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsAtrial Fibrillation $115,869
End Stage Renal Disease $115,331
Other Ankle Sprain And Strain $114,431
Coronary Atherosclerosis Of Native Coronary Vessel $113,103
Contracture, Left Elbow $110,717
End Stage Renal Disease $110,575
Sensitive Diagnosis $110,534
Malignant Neoplasm Of Other Specified Sites Of Female Breast $109,855
Malignant Neoplasm Of Prostate $104,998
Sensitive Diagnosis $103,588
Trigeminal Neuralgia $103,534
Coronary Atherosclerosis Of Native Coronary Vessel $102,675
Sensitive Diagnosis $102,132
Chronic Or Unspecified Parametritis And Pelvic Cellulitis $100,640
Malignant Neoplasm Of Pancreas, Part Unspecified $99,819
Acute And Chronic Respiratory Failure $99,186
Orchitis And Epididymitis, Unspecified $95,329
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 88 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsChronic Myeloid Leukemia, Without Mention Of Having Achieved Remission $93,657
Other Hammer Toe (acquired) $93,028
Quadriplegia, C5-c7, Incomplete $88,174
Sensitive Diagnosis $86,651
Multiple Sclerosis $85,544
Multiple Sclerosis $83,894
Malignant Carcinoid Tumor Of The Small Intestine, Unspecified Portion $83,560
Atrial Fibrillation $83,280
Nonunion Of Fracture $83,031
Radiculopathy, Lumbar Region $82,624
Multiple Sclerosis $82,549
Sensitive Diagnosis $80,560
Sensitive Diagnosis $80,159
Malignant Neoplasm Of Lower Lobe, Bronchus Or Lung $78,194
Encounter For Antineoplastic Radiation Therapy $78,122
Hypertrophy Of Breast $77,680
Regional Enteritis Of Small Intestine $76,282
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 89 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsCoronary Atherosclerosis Of Native Coronary Vessel $76,212
Volvulus $75,175
Acute Myocardial Infarction, Subendocardial Infarction, Initial Episode Of Care $74,885
Regional Enteritis Of Small Intestine With Large Intestine $74,801
Multiple Sclerosis $74,535
Sensitive Diagnosis $74,088
Multiple Sclerosis $73,636
Unspecified Chest Pain $72,287
Fitting And Adjustment Of Automatic Implantable Cardiac Defibrillator $72,149
Other Polyp Of Sinus $71,379
Sensitive Diagnosis $70,970
Sensitive Diagnosis $70,651
Retention Of Urine, Unspecified $69,713
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $69,475
Sensitive Diagnosis $69,097
Other B-complex Deficiencies $68,689
Bilateral Partial Paralysis Of Vocal Cords Or Larynx $68,642
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 90 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsCalculus Of Kidney $68,431
Rheumatic Fever Without Heart Involvement $68,283
Supraventricular Tachycardia $68,265
Encounter For Antineoplastic Chemotherapy $67,980
Leukoplakia Of Oral Mucosa, Including Tongue $67,832
Sensitive Diagnosis $67,594
Type 1 Diabetes Mellitus Without Complications $67,326
Rectal Prolapse $66,271
Sensitive Diagnosis $65,450
Hallux Valgus (acquired) $63,616
Closed Fracture Of Humerus, Supracondylar $63,502
Coronary Atherosclerosis Of Native Coronary Vessel $63,182Unspecified Disorders Of Menstruation And Other Abnormal Bleeding From FemaleGenital Tract $63,127
Sensitive Diagnosis $63,091
Coronary Atherosclerosis Of Native Coronary Vessel $62,920
Sensitive Diagnosis $62,406
Other Primary Cardiomyopathies $62,238
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 91 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsBell's Palsy $60,179
Cortical Age-related Cataract, Left Eye $59,294
Sensitive Diagnosis $59,205
Open Bite Of Left Thumb Without Damage To Nail, Initial Encounter $58,871
Regional Enteritis Of Small Intestine With Large Intestine $57,715
Craniosynostosis $57,678
Malignant Neoplasm Of Ovary $57,005
Other Complications Due To Internal Joint Prosthesis $56,836
Acute Systolic (congestive) Heart Failure $56,779
Atherosclerosis Of Native Arteries Of Extremities With Ulceration $55,800
Eosinophilia $55,724
Other Mechanical Complication Of Cardiac Electrode, Initial Encounter $55,214
Encounter For Breast Reconstruction Following Mastectomy $54,951
Other And Unspecified Creutzfeldt-jakob Disease $54,832
Sensitive Diagnosis $54,228
Multiple Sclerosis $54,162
Cystic Fibrosis Without Mention Of Meconium Ileus $52,860
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 92 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsNonpyogenic Meningitis $51,993Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $51,833
Acute Osteomyelitis, Ankle And Foot $51,272
Other Chest Pain $51,250
Displacement Of Lumbar Intervertebral Disc Without Myelopathy $51,200Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $51,066
Morbid (severe) Obesity Due To Excess Calories $50,706
Encephalocele $50,626
Deviated Nasal Septum $50,151
Rheumatoid Arthritis $50,062
Rheumatoid Arthritis $48,734
Unspecified Ventral Hernia Without Mention Of Obstruction Or Gangrene $48,583
Sensitive Diagnosis $48,154
Cellulitis Of Right Toe $47,732
Neuralgia, Neuritis, And Radiculitis, Unspecified $47,656
Other Allied Disorders Of Spine $47,536
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 93 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsMorbid Obesity $47,517
Cirrhosis Of Liver Without Mention Of Alcohol $47,492
Coronary Atherosclerosis Of Native Coronary Vessel $47,276
Hodgkin's Disease, Nodular Sclerosis, Unspecified Site, Extranodal And Solid Organ Sites $47,255
Sensitive Diagnosis $46,360
Other Specified Diseases Of Pancreas $46,273
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $46,267
Sensitive Diagnosis $46,195
Encounter For Antineoplastic Radiation Therapy $45,814
Sensitive Diagnosis $45,806
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $45,760
Sensitive Diagnosis $45,439
Osteoarthrosis, Localized, Primary, Lower Leg $45,413
Unspecified Iridocyclitis $45,355
Sensitive Diagnosis $45,125
Unspecified Inflammatory Polyarthropathy $44,987
Sensitive Diagnosis $44,408
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 94 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsPrecocious Sexual Development And Puberty, Not Elsewhere Classified $44,195
Acute Myocardial Infarction, Subendocardial Infarction, Initial Episode Of Care $43,669
Incomplete Rotator Cuff Tear Or Rupture Of Right Shoulder, Not Specified As Traumatic $43,662
Malignant Neoplasm Of Rectum $43,268
Other Pulmonary Embolism And Infarction $42,818
Malignant Neoplasm Of Upper-outer Quadrant Of Female Breast $42,756
Acute Myocardial Infarction, Of Other Anterior Wall, Initial Episode Of Care $42,088
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $41,809
Coronary Atherosclerosis Of Native Coronary Vessel $41,686
Unspecified Chest Pain $41,510
Sensitive Diagnosis $41,468
Sensitive Diagnosis $41,466
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $41,443
Other Psoriasis $41,442
Deviated Nasal Septum $41,272
Malignant Neoplasm Of Ovary $41,252
Syncope And Collapse $41,224
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 95 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsUnilateral Primary Osteoarthritis, Right Knee $40,835
Malignant Neoplasm Of Upper-outer Quadrant Of Left Female Breast $40,535Atherosclerotic Heart Disease Of Native Coronary Artery With Other Forms Of AnginaPectoris $40,443
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $40,242
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $40,188
Sensitive Diagnosis $39,926Displaced Fracture Of Acromial Process, Left Shoulder, Initial Encounter For ClosedFracture $39,896
Unilateral Primary Osteoarthritis, Left Knee $39,889
Diabetes Mellitus Without Mention Of Complication, Type I [juvenile Type], Uncontrolled $39,783
Post-traumatic Headache, Unspecified, Not Intractable $39,595
Unilateral Primary Osteoarthritis, Left Knee $39,514
Calculus Of Bile Duct Without Cholangitis Or Cholecystitis Without Obstruction $39,220
Atherosclerotic Heart Disease Of Native Coronary Artery With Unstable Angina Pectoris $38,914
Primary Focal Hyperhidrosis $38,812
Other Selective Immunoglobulin Deficiencies $38,399
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $38,305
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 96 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsIncisional Hernia Without Mention Of Obstruction Or Gangrene $38,264
Displacement Of Cervical Intervertebral Disc Without Myelopathy $38,078
Calculus Of Gallbladder And Bile Duct With Acute Cholecystitis Without Obstruction $38,014Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, ShoulderRegion $37,882
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $37,521
Diverticulitis Of Colon (without Mention Of Hemorrhage) $37,488
Acute On Chronic Systolic Heart Failure $37,406
Sensitive Diagnosis $37,222
Acute Myocardial Infarction, Subendocardial Infarction, Initial Episode Of Care $37,172
End Stage Renal Disease $36,516
Supraventricular Tachycardia $36,215
Morbid Obesity $36,136
Sensitive Diagnosis $36,115
Osteoarthrosis, Unspecified Whether Generalized Or Localized, Hand $36,030
Other Polyp Of Sinus $35,989
Displacement Of Lumbar Intervertebral Disc Without Myelopathy $35,968
Acute Kidney Failure, Unspecified $35,910
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 97 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsSensitive Diagnosis $35,884
Urticaria, Unspecified $35,741
Thrombotic Microangiopathy $35,678
Rheumatoid Arthritis $35,527
Closed Fracture Of C5-c7 Level With Unspecified Spinal Cord Injury $35,445
Sensitive Diagnosis $35,370
Synovitis And Tenosynovitis, Unspecified $35,327
Solitary Pulmonary Nodule $35,213
Malignant Neoplasm Of Prostate $35,207
Ulcerative Colitis, Unspecified $34,844
Acute Myocardial Infarction, Subendocardial Infarction, Initial Episode Of Care $34,783
Polyarticular Juvenile Rheumatoid Arthritis, Chronic Or Unspecified $34,737
Supraventricular Tachycardia $34,445
Unspecified Septicemia $34,400
Sensitive Diagnosis $34,272
Postprocedural Intestinal Obstruction $34,159
Multiple Sclerosis $33,774
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 98 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsCoronary Atherosclerosis Of Native Coronary Vessel $33,737
Sprain Of Right Rotator Cuff Capsule, Initial Encounter $33,676
Unspecified Disorder Of Male Genital Organs $33,636
Sensitive Diagnosis $33,624
Ventral Hernia Without Obstruction Or Gangrene $33,477
Encounter For Checking And Testing Of Cardiac Pacemaker Pulse Generator [battery] $33,418
Deviated Nasal Septum $33,414
Morbid (severe) Obesity Due To Excess Calories $33,407
Calculus Of Kidney $33,357
Urinary Tract Infection, Site Not Specified $33,273
Sinoatrial Node Dysfunction $33,157
Hallux Valgus (acquired) $33,153
Occlusion And Stenosis Of Carotid Artery Without Mention Of Cerebral Infarction $33,106Diabetes With Unspecified Complication, Type I [juvenile Type], Not Stated AsUncontrolled $33,055
Sensitive Diagnosis $32,930
Closed Trimalleolar Fracture $32,856
Loss Of Weight $32,849
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 99 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsOther Postoperative Infection $32,723Diabetes With Neurological Manifestations, Type I [juvenile Type], Not Stated AsUncontrolled $32,660
Sensitive Diagnosis $32,636
Sensitive Diagnosis $32,620
Sensitive Diagnosis $32,498
Sensitive Diagnosis $32,488
Umbilical Hernia Without Mention Of Obstruction Or Gangrene $32,476
Sensitive Diagnosis $32,431Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $32,190
Sensitive Diagnosis $32,135
Abdominal Pain, Unspecified Site $31,948
Other Psoriasis $31,790
Osteoporosis, Unspecified $31,777
Obstructive Hydrocephalus $31,657
Calculus Of Kidney $31,430
Sensitive Diagnosis $31,328
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 100 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsCervicalgia $31,027Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $30,916
Displacement Of Cervical Intervertebral Disc Without Myelopathy $30,899
Acute On Chronic Systolic Heart Failure $30,835
Sensitive Diagnosis $30,819
Other Polyp Of Sinus $30,805
Osteoarthritis Of Knee, Unspecified $30,742
Sensitive Diagnosis $30,682
Sensitive Diagnosis $30,483
Chronic Ethmoidal Sinusitis $30,414
Hidradenitis $30,406
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $30,398
Coronary Atherosclerosis Of Native Coronary Vessel $30,348
Unspecified Site Of Foot Sprain And Strain $30,287
Sensitive Diagnosis $30,026
Excessive And Frequent Menstruation With Irregular Cycle $30,020
Morbid Obesity $29,994
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 101 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsHyperparathyroidism, Unspecified $29,909
Sensitive Diagnosis $29,899
Unilateral Primary Osteoarthritis, Right Knee $29,766
Other Inflammatory Disorders Of Male Genital Organs $29,648
Sensitive Diagnosis $29,453
Hairy Cell Leukemia Not Having Achieved Remission $29,382
Type 1 Diabetes Mellitus With Diabetic Neuropathy, Unspecified $29,206
Other Chest Pain $29,141
Pain In Limb $29,073
Hypogammaglobulinemia, Unspecified $29,040
Primary Pulmonary Hypertension $29,011
Hydronephrosis With Renal And Ureteral Calculous Obstruction $29,006
Sensitive Diagnosis $28,931
Postmenopausal Bleeding $28,894
Calculus Of Bile Duct With Acute And Chronic Cholecystitis Without Obstruction $28,819
Leiomyoma Of Uterus, Unspecified $28,775
Persistent Atrial Fibrillation $28,771
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 102 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsEncounter For Removal Of Internal Fixation Device $28,696
Sensitive Diagnosis $28,633
Hypertrophy Of Nasal Turbinates $28,339Nonspecific (abnormal) Findings On Radiological And Other Examination Of GenitourinaryOrgans $28,311
Poisoning By Other And Unspecified Anticonvulsants $28,092
Pelvic Peritoneal Adhesions, Female (postoperative) (postinfection) $28,028
Ankylosing Spondylitis $28,027Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, ShoulderRegion $27,886
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $27,808
Sensitive Diagnosis $27,657
Multiple Sclerosis $27,604
Supraspinatus (muscle) (tendon) Sprain And Strain $27,459
Sensitive Diagnosis $27,431
Cervicalgia $27,415
Diabetes With Ketoacidosis, Type I [juvenile Type], Uncontrolled $27,356
Morbid Obesity $27,348
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 103 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsMechanical Complication Due To Corneal Graft $27,283
Care Involving Other Physical Therapy $27,230
Sensitive Diagnosis $27,203
Sensitive Diagnosis $27,148
Leiomyoma Of Uterus, Unspecified $27,093Localization-related (focal) (partial) Symptomatic Epilepsy And Epileptic Syndromes WithSimple Partial Seizures, Not Intractable, With Status Epilepticus $27,088
Febrile Convulsions (simple), Unspecified $27,077
Bicipital Tendinitis, Right Shoulder $27,002
Calculus Of Gallbladder With Chronic Cholecystitis Without Obstruction $26,996
Other Chronic Nonalcoholic Liver Disease $26,842
Flatulence, Eructation, And Gas Pain $26,806
Loose Body In Ankle And Foot Joint $26,759
Cardiac Murmur, Unspecified $26,712
Sensitive Diagnosis $26,668
Acute And Chronic Respiratory Failure $26,627
Sensitive Diagnosis $26,596
Non-st Elevation (nstemi) Myocardial Infarction $26,534
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 104 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsOsteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Pelvic RegionAnd Thigh $26,528
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $26,505
Osteoarthrosis, Localized, Primary, Lower Leg $26,500
Acute Pancreatitis, Unspecified $26,475
Spinal Stenosis, Lumbar Region, Without Neurogenic Claudication $26,432
Unspecified Chest Pain $26,265
Dermatochalasis $26,212
Diaphragmatic Hernia Without Mention Of Obstruction Or Gangrene $26,156
Rheumatoid Arthritis $26,133
Hypo-osmolality And Hyponatremia $26,102
Lumbosacral Spondylosis Without Myelopathy $25,968
Mandibular Hyperplasia $25,941
Closed Fractures Of Other Part Of Distal End Of Radius (alone) $25,924
Calculus Of Gallbladder With Chronic Cholecystitis Without Obstruction $25,916
Acute Myocardial Infarction, Unspecified Site, Subsequent Episode Of Care $25,896
Articular Cartilage Disorder, Pelvic Region And Thigh $25,839
Posterior Subcapsular Polar Senile Cataract $25,791
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 105 of 106
Ramsey County [12900]
Paid through 01/31/2016Service Dates of 01/01/2015 through 12/31/2015
Medical Catastrophic Cases
Principal Diagnosis ClaimsNontraumatic Subacute Subdural Hemorrhage $25,739
Calculus Of Gallbladder With Other Cholecystitis, Without Mention Of Obstruction $25,717
Psoriasis Vulgaris $25,628
Sprain And Strain Of Other Specified Sites Of Hip And Thigh $25,626
Sensitive Diagnosis $25,625
Osteoarthrosis, Localized, Not Specified Whether Primary Or Secondary, Lower Leg $25,578
Lesion Of Ulnar Nerve, Left Upper Limb $25,483Laceration Without Foreign Body Of Left Ring Finger Without Damage To Nail, InitialEncounter $25,481
Epilepsy, Unspecified, Without Mention Of Intractable Epilepsy $25,265
Unspecified Intestinal Obstruction $25,257
Sensitive Diagnosis $25,232
Hypoparathyroidism $25,028
Total $22,477,050
Total Above $25,000 $13,777,050
Note: Claims do not include IBNR
All Packages/All Sites YTD Qtrly
Prior Year
Report Period: 2/1/2017 12:00:0Run Date: 02/17/2017
© Copyright 2017 HealthPartners420_Ex_Catastrophic_CasesReport Id: 43735
Page 106 of 106
RFP - HR1809 MEDICAL BENEFITS
TOP PROVIDERS DISRUPTION 2017
APPENDIX F
1 of 6
Provider Claimants Claims
HEALTHPARTNERS MEDICAL GROUP 3,603 $4,925,871
ST PAUL RADIOLOGY PA 1,259 $273,851
HEALTHPARTNERS WORKSITE HEALTH 587 $19,828
FULCRUM HEALTH,INC 535 $79,956
NOT APPLICABLE 458 $15,425
PARK NICOLLET CLINIC 376 $597,521
MINUTECLINIC DIAGNOSTIC OF MN PA 311 $18,590
EMERGENCY PHYSICIANS,PA 288 $195,278
HEALTHPARTNERS MENTAL HEALTH 285 $252,814
REGIONS HOSPITAL-PRO FEE 277 $156,930
DERMATOLOGY CONSULTANTS,PA 275 $118,523
HOSPITAL PATHOLOGY ASSOCIATES 275 $47,546
SUMMIT ORTHOPEDICS,LTD 268 $322,211
ST PAUL EYE CLINIC,PA 242 $78,778
VIRTUWELL 242 $14,339
MINNESOTA GASTROENTEROLOGY PA 240 $334,440
HEALTHPARTNERS MEDICAL GROUP-NW ALLIANCE 234 $180,553
SUBURBAN RADIOLOGIC CONSULTANTS 220 $44,500
ALLINA MEDICAL CLINIC-WOODBURY 209 $170,074
QUEST DIAGNOSTICS,LLC 199 $21,303
MINUTECLINIC,LLC 190 $22,963
Current Year by Claimant Count
Ramsey County [12900]
Provider Report
Service Dates of 01/01/2017 through 12/31/2017
Paid through 12/31/2017
Top 50 Providers - Professional
RFP - HR1809 MEDICAL BENEFITS
TOP PROVIDERS DISRUPTION 2017
APPENDIX F
2 of 6
TWIN CITIES ORTHOPEDICS,PA 180 $227,967
STILLWATER MEDICAL GROUP-CURVE CREST 178 $119,519
PREMIER OBGYN OF MINNESOTA 168 $181,890
CENTER FOR DIAG IMAGING-MPLS 158 $119,717
THE URGENCY ROOM-VADNAIS HEIGHTS 158 $87,701
ALLINA MEDICAL SYSTEM-BANDANA SQUARE CLINIC 150 $121,725
ASSOCIATED ANESTHESIOLOGISTS PA 149 $189,144
COMMUNITY ANESTHESIA PROFESSIONALS PLLC 149 $96,959
LUXOTTICA RETAIL NORTH AMERICA INC 145 $7,671
UNIVERSITY OF MN PHYSICIANS-SPECIALTY 144 $149,525
ASSOCIATED EYE CARE LTD 134 $41,068
EMERGENCY CARE CONSULTANTS,PA-MPLS 133 $88,348
TRIA ORTHOPAEDIC CENTER LLC 130 $130,950
REGIONS HOSPITAL-PHYSICAL THERAPY 128 $48,086
HEALTHEAST HEART CARE-ST JOHNS 121 $110,957
HEALTHEAST MAPLEWOOD CLINIC 119 $52,274
METROPOLITAN ANESTHESIA NETWORK LLP 106 $107,510
CENTRAL PEDIATRICS,PA-WOODBURY 103 $58,193
ALLINA MEDICAL CLINIC-COTTAGE GROVE 96 $74,957
HEALTHEAST ST JOHNS & MIDWAY 94 $34,757
HUDSON PHYSICIANS 94 $79,857
MAYO CLINIC ROCHESTER 93 $795,456
PEDIATRIC RADIOLOGY PA 93 $10,576
MIDWEST ENT SPECIALISTS 91 $72,698
MINNESOTA UROLOGY PA 89 $45,539
ALLINA MEDICAL CLINIC-COON RAPIDS 83 $56,743
HEALTHEAST WOODBURY CLINIC 82 $42,190
CHILDRENS HEALTH CARE-ST PAUL ER PHYS 78 $29,614
UNIVERSITY OF MINNESOTA HEALTH CLINIC 77 $86,193
Note: Claims do not include IBNR
RFP - HR1809 - MEDICAL BENEFITS
TOP PROVIDERS DISRUPTION 2017
APPRENDIX F
3 of 6 2/22/2018
Provider Claimants Claims
REGIONS HOSPITAL-RAD/ACUTE/SLEEP 82 $1,083,890
HEALTHEAST ST JOHNS & MIDWAY 53 $564,831
UNITED HOSPITAL 32 $558,080
HEALTHEAST WOODWINDS HOSPITAL 30 $307,899
HEALTHEAST ST JOSEPHS 21 $299,480
ABBOTT NORTHWESTERN HOSPITAL 17 $175,479
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW WEST 17 $419,186
FAIRVIEW SOUTHDALE HOSPITAL 15 $332,689
FAIRVIEW RIDGES HOSPITAL 12 $111,842
MERCY HOSPITAL 12 $187,120
MAPLE GROVE HOSPITAL 11 $74,054
PARK NICOLLET METHODIST HOSPITAL-ACUTE 11 $201,064
CHILDRENS HEALTH CARE-ST PAUL 9 $201,868
CHILDRENS HEALTH CARE-MPLS 8 $501,595
LAKEVIEW HOSPITAL 8 $119,326
FAIRVIEW LAKES REGIONAL MEDICAL CENTER 7 $52,818
MAYO CLINIC HOSPITAL-ROCHESTER 7 $175,598
ABBOTT NORTHWESTERN HOSPITAL-PSYCH_ 6 $109,086
NORTH MEMORIAL HEALTH CARE 6 $148,974
ANNA WESTIN HOUSE 5 or under $35,129
ANTHONY LOUIS CENTER 5 or under $14,997
Current Year by Claimant Count
Ramsey County [12900]
Provider Report
Service Dates of 01/01/2017 through 12/31/2017
Paid through 12/31/2017
Top 50 Providers - Hospital IP
RFP - HR1809 - MEDICAL BENEFITS
TOP PROVIDERS DISRUPTION 2017
APPRENDIX F
4 of 6 2/22/2018
BEAUTERRE RECOVERY INSTITUTE 5 or under $32,426
BOULDER COMMUNITY HOSPITAL 5 or under $19,558
BROWN COUNTY EVALUATION CENTER, INC 5 or under $1,263
CAMBRIDGE MEDICAL CENTER 5 or under $18,285
CARECHOICE-WALKER METHODIST II 5 or under $21,949
EPISCOPAL CHURCH HOME OF MINNESOTA 5 or under $8,500
EXTENDED CARE TRANSITIONS 5 or under $19,036
FAIRVIEW RESIDENTIAL & RECOVERY SERVICES FOR ADOLESCENTS 5 or under $37,465
FAIRVIEW SOUTHDALE HOSPITAL-PSYCH 5 or under $12,928
FAIRVIEW UNIVERSITY TRANSITIONAL SERVICES 5 or under $21,757
GILLETTE CHILDRENS HOSPITAL 5 or under $100,846
HAZELDEN CENTER CITY 5 or under $97,154
HAZELDEN CENTER FOR YOUTH AND FAMILY 5 or under $20,669
HILLCREST OF WAYZATA REHAB & HEALTHCARE CENTER 5 or under $22,913
HUDSON HOSPITAL INC-CRITICAL ACCESS 5 or under $24,989
LYNGBLOMSTEN CARE CENTER 5 or under $38,936
MAPLEWOOD CARE CENTER 5 or under $12,700
MCHS IN EAU CLAIRE-ACUTE 5 or under $30,440
MCHS MANKATO HOSPITAL 5 or under $27,507
MCHS RED WING 5 or under $39,427
PARK NICOLLET HEALTH SERVICES 5 or under $30,195
PSJ ACQUISITION, LLC 5 or under $47,339
RIDGEVIEW MEDICAL CENTER 5 or under $36,879
SANFORD 5 or under $74,874
SENTARA NORTHERN VIRGINIA MEDICAL CENTER 5 or under $15,799
ST LUKE'S HOSPITAL 5 or under $79,852
SUBURBAN HOSPITAL-BETHESDA 5 or under $15,520
VILLA AT OSSEO,LLC 5 or under $21,877
WOODBURY HEALTH CARE CENTER,INC 5 or under $77,153
Note: Claims do not include IBNR
RFP - HR1809 MEDICAL BENEFITS
TOP PROVIDERS DISRUPTION 2017
APPENDIX F
5 of 6 2/22/2018
Provider Claimants Claims
REGIONS HOSPITAL-RAD/ACUTE/SLEEP 796 $2,058,097
HEALTHPARTNERS SAME DAY SURG CENTER 257 $450,691
HEALTHEAST ST JOHNS & MIDWAY 242 $417,702
UNIVERSITY OF MINNESOTA MEDICAL CENTER, FAIRVIEW WEST 208 $371,021
UNITED HOSPITAL 202 $567,192
CHILDRENS HEALTH CARE-ST PAUL 160 $301,060
HEALTHEAST WOODWINDS HOSPITAL 141 $229,220
ABBOTT NORTHWESTERN HOSPITAL 121 $244,191
FAIRVIEW LAKES REGIONAL MEDICAL CENTER 96 $106,725
MNGI ENDOSCOPY-MAPLEWOOD 88 $83,398
LAKEVIEW HOSPITAL 86 $130,704
CHILDRENS HEALTH CARE-MPLS 84 $89,893
ABBOTT NORTHWESTERN HOSPITAL-LAB 82 $14,591
FAIRVIEW RIDGES HOSPITAL 79 $86,212
MERCY HOSPITAL 75 $173,184
PARK NICOLLET METHODIST HOSPITAL-ACUTE 71 $139,175
FAIRVIEW SOUTHDALE HOSPITAL 62 $173,696
HEALTHEAST ST JOSEPHS 62 $125,060
HEALTHEAST MEDICAL LABORATORY 60 $5,540
MNGI ENDOSCOPY ASC INC 51 $49,699
HUDSON HOSPITAL INC-CRITICAL ACCESS 48 $108,517
Current Year by Claimant Count
Ramsey County [12900]
Provider Report
Service Dates of 01/01/2017 through 12/31/2017
Paid through 12/31/2017
Top 50 Providers - Hospital OP
RFP - HR1809 MEDICAL BENEFITS
TOP PROVIDERS DISRUPTION 2017
APPENDIX F
6 of 6 2/22/2018
Provider Claimants Claims
REGIONS HOSPITAL-PHYSICAL THERAPY 47 $11,023
GILLETTE CHILDRENS HOSPITAL 39 $128,268
MAYO CLINIC HOSPITAL-ROCHESTER 35 $400,093
HENNEPIN COUNTY MEDICAL CENTER 33 $97,246
HEALTHEAST HOME CARE 29 $8,688
NORTH MEMORIAL HEALTH CARE 27 $95,690
REGINA HOSPITAL ACUTE CARE 27 $46,660
DBA DVA-CENTRAL PLAINS CPAC 24 $28,324
HIGH POINTE SURGERY CENTER 24 $63,870
ST CROIX REGIONAL MEDICAL CENTER 23 $47,691
MAPLE GROVE HOSPITAL 21 $21,351
MIDWEST SURGERY CENTER 20 $38,388
SUMMIT ORTHOPEDICS,LTD 20 $70,917
WESTERN WISCONSIN HEALTH 20 $34,873
MINNESOTA ENDOSCOPY CENTER,LLC 19 $18,510
WESTFIELDS HOSPITAL 19 $58,502
ALLINA HEALTH SYSTEM-OB HOMECARE 17 $3,170
RIVER FALLS AREA HOSPITAL 17 $57,384
ST FRANCIS REGIONAL MEDICAL CENTER 16 $44,913
NORTHFIELD CITY HOSPITAL 15 $49,516
PHILLIPS EYE INSTITUTE 15 $75,895
NYSTROM & ASSOCIATES 12 $23,060
NORTH MEMORIAL HEALTH CARE-REFERENCE LAB 11 $1,200
SUMMIT ORTHOPEDICS LTD-EAGAN 10 $33,830
HEALTHEAST SURGERY CENTER-MAPLEWOOD 9 $33,426
LANDMARK SURGERY CENTER 9 $15,395
MCHS MANKATO HOSPITAL 9 $22,681
RIDGEVIEW MEDICAL CENTER 9 $25,502
TRIA ORTHOPAEDIC CENTER 8 $13,098
Note: Claims do not include IBNR
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
1 of 23 9:57 AM
Ramsey County
Retail Network Match
• In column G, please state whether or not the pharmacy is within your pharmacy network by marking "Y" if it is included and "N" if it is not included
• In column H, enter any comments that are applicable ("permanently closed", "solicitable", ect.)• Do not delete rows or columns or change the exhibit in such a way that the data provided here is altered
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2425115 MERWIN LONG TERM CARE PHARMACY 1811 OLD HIGHWAY 8 NEW BRIGHTON MN 55112
2428616 WALGREENS #1751 2920 WHITE BEAR AVE N MAPLEWOOD MN 55109
2420886 WALGREENS #13685 2635 RICE STREET ROSEVILLE MN 55113
2421220 WALGREENS #3122 985 GENEVA AVE OAKDALE MN 55128
2418603 WALGREENS #9795 1585 RANDOLPH AVE ST PAUL MN 55105-2149
2413110 HEALTHPARTNERS ST. PAUL PHARMACY 205 WABASHA ST S SAINT PAUL MN 55107
2402991 WALGREENS 7135 E POINT DOUGLAS RD S COTTAGE GROVE MN 55016
2421749 WALGREENS #3187 1075 HIGHWAY 96 EAST WHITE BEAR LAKE MN 55127
2423820 WALGREENS #6056 1965 DONEGAL DRIVE WOODBURY MN 55125
2401444 SETZER PHARMACY 1685 RICE ST ROSEVILLE MN 55113
2420571 HEALTHPARTNERS WOODBURY PHARMACY8450 SEASONS PKWY WOODBURY MN 55125
2400656 CVS PHARMACY # 1515 COUNTY ROAD B W ROSEVILLE MN 55113
2418045 WALGREENS #15272 1110 LARPENTEUR AVE W ST PAUL MN 55113
2418893 WALGREENS #2142 734 GRAND ST PAUL MN 55105
2414871 WALGREENS #2805 1133 S ROBERT WEST ST PAUL MN 55118
2420052 WALGREENS #10188 7040 VALLEY CREEK WOODBURY MN 55125-1559
2413780 CVS PHARMACY # 1744 SUBURBAN AVE SAINT PAUL MN 55106
2420608 HEALTHPARTNERS ARDEN HILLS PHARMAC3930 NORTHWOODS DR ARDEN HILLS MN 55112-6974
2419895 CVS PHARMACY # 3800 LEXINGTON AVE N SHOREVIEW MN 55126
2408474 ST PAUL CORNER DRUG 240 S SNELLING AVE ST PAUL MN 55105
2421799 CUB PHARMACY 2390 WHITE BEAR AVE N MAPLEWOOD MN 55109
2425658 WALGREENS #7388 1665 WHITE BEAR AVE N ST PAUL MN 55106
2426763 CVS PHARMACY 4800 HWY 61 WHITE BEAR LAKE MN 55110
2415378 HEALTHPARTNERS WHITE BEAR LAKE PHA1430 HWY 96 WHITE BEAR LAKE MN 55110
2423212 WALGREENS #4882 5825 CAHILL AVE INVER GROVE HEIGHTS MN 55076
2413108 HEALTHPARTNERS COMO PHARMACY 2500 COMO AVE SAINT PAUL MN 55108-1494
2425557 WALGREENS #7111 1207 W BROADWAY AVE FOREST LAKE MN 55025
2419958 WALGREENS 915 WILDWOOD RD WHITE BEAR LAKE MN 55115-1847
2402179 CVS PHARMACY # 2199 HWY 36 E NORTH SAINT PAUL MN 55109
2430798 WHITE BEAR HEALTH MART PHARMACY 2008 EAST COUNTY ROAD E WHITE BEAR LAKE MN 55110-7333
2429290 WALGREENS #12403 600 VILLAGE CENTER DR NORTH OAKS MN 55127
2420127 CVS PHARMACY # 7200 VALLEY CREEK PLZ WOODBURY MN 55125
2427513 CVS PHARMACY # 7900 32ND ST N OAKDALE MN 55128
2425052 WALGREENS #6995 1788 OLD HUDSON RD ST PAUL MN 55119
2430685 WALGREENS 2099 FORD PKWY SAINT PAUL MN 55116-1814
2415354 CVS PHARMACY # 1300 UNIVERSITY AVE W SAINT PAUL MN 55104
2400214 WALGREENS #16476 398 WABASHA ST ST PAUL MN 55101
2426383 CVS PHARMACY 810 MARYLAND AVE E ST PAUL MN 55106
2400719 CVS PHARMACY # 1750 ROBERT ST S WEST ST PAUL MN 55118
2420595 HEALTHPARTNERS INVER GROVE HEIGHTS 5625 CENEX DR INVER GROVE HEIGHTS MN 55077-1724
2420444 WALMART PHARMACY 10-1861 5815 NORELL AVE OAK PARK HEIGHTS MN 55082
2430546 WALGREENS 790 HIGHWAY 110 MENDOTA HEIGHTS MN 55120-1509
2422208 CVS PHARMACY # 975 COUNTY ROAD E VADNAIS HEIGHTS MN 55127
2427195 CVS PHARMACY 2196 WHITE BEAR N MAPLEWOOD MN 55109
2421650 WALMART PHARMACY 10-2274 200 SW 12TH ST FOREST LAKE MN 55025
2424834 CVS PHARMACY # 749 APOLLO DR LINO LAKES MN 55014
2421294 WALMART PHARMACY 10-2087 850 EAST COUNTY RD E VADNAIS HEIGHTS MN 55127
2428337 WALGREENS 1700 RICE ST SAINT PAUL MN 55113-6812
Total Pharmacies in Proposed Network
• The pharmacies included below include all the pharmacies used by Ramsey County members in 2017. Based on the NABP numbers listed below,
please identify if the pharmacy listed is in your proposed network.
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
2 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2425088 CUB PHARMACY 7850 CAHILL DR INVER GROVE HEIGHTS MN 55076
2400199 WALGREENS 1401 E MARYLAND AVE ST PAUL MN 55106-2823
2416623 CUB PHARMACY 1801 MARKET DR STILLWATER MN 55082
2427020 HEALTHPARTNERS SPECIALTY CENTER PH 401 PHALEN BLVD ST PAUL MN 55130-5302
2427537 THRIFTY WHITE DRUG #762 6055 NATHAN LN N STE 200A PLYMOUTH MN 55442-1674
2421509 REGIONS HOSPITAL OUTPATIENT PHARMA640 JACKSON ST ST PAUL MN 55101-2595
2425937 WALGREENS #6916 6061 OSGOOD AVE N OAK PARK HEIGHTS MN 55082
2423565 CVS PHARMACY # 356 12TH ST SW FOREST LAKE MN 55025
3958898 CVS/SPECIALTY #02921 105 MALL BOULEVARD MONROEVILLE PA 15146
5133133 WALGREENS 141 CARMICHAEL RD HUDSON WI 54016-7716
2416813 CUB PHARMACY 100 W COUNTY RD B MAPLEWOOD MN 55117
2426496 WALGREENS #7218 12480 ABERDEEN ST NE BLAINE MN 55449
2422474 FAIRVIEW LAKES PHARMACY WYOMING 5200 FAIRVIEW BOULEVARD WYOMING MN 55092
5125100 CVS PHARMACY # 2401 COULEE RD HUDSON WI 54016
2420583 HEALTHPARTNERS MIDWAY PHARMACY 451 DUNLAP ST N SAINT PAUL MN 55104-4619
2425925 CUB PHARMACY 2197 HUDSON RD ST PAUL MN 55119
2421307 WALGREENS #3423 9273 LAKE DRIVE LEXINGTON MN 55014
2423375 WALGREENS #5081 4220 LEXINGTON AVE EAGAN MN 55123
2408537 LLOYDS PHARMACY 720 SNELLING AVE N SAINT PAUL MN 55104-1885
2417384 OMNICARE MINNESOTA 4001 LAKE BREEZE AVE BROOKLYN CENTER MN 55429
5122407 WALMART PHARMACY 10-2421 2212 GLACIER DRIVE ST CROIX FALLS WI 54024
2424214 WALGREENS #6447 2387 HIGHWAY 10 MOUNDS VIEW MN 55112
2429668 CVS PHARMACY #07406 8468 TAMARACK BAY WOODBURY MN 55125-3738
2431524 WALGREENS 3585 LEXINGTON AVE N ARDEN HILLS MN 55126
2427082 CVS PHARMACY #05998 499 SNELLING AVE N SAINT PAUL MN 55104
2428628 WALGREENS #11421 1180 ARCADE ST SAINT PAUL MN 55106-2629
2400175 WALGREENS #828 12 W 66TH ST RICHFIELD MN 55423
2421143 WALGREENS #2935 10686 UNIVERSITY NW COON RAPIDS MN 55448
2414148 LINDSTROM THRIFTY WHITE PHARMACY 30699 LINCOLN RD LINDSTROM MN 55045-0692
2426484 WALMART PHARMACY 10-3364 1644 SOUTH ROBERT STREET SO WEST ST PAUL MN 55118
2422119 CUB PHARMACY 3930 SILVER LAKE RD ST ANTHONY MN 55421
5133626 WESTFIELDS COMMUNITY PHARMACY 535 HOSPITAL RD NEW RICHMOND WI 54017-1449
2432475 CUB PHARMACY #1589 7191 10TH ST N OAKDALE MN 55128
2425507 WALGREENS #6943 4560 S ROBERT TRL INVER GROVE HEIGHTS MN 55077
2425951 WALMART PHARMACY 10-5437 1450 UNIVERSITY AVENUE WEST ST PAUL MN 55104
2432324 HEALTHPARTNERS UNIVERSITY AVENUE P 2635 UNIVERSITY AVE, SUITE 160 SAINT PAUL MN 55114
2424923 SAMS PHARMACY 10-6312 9925 HUDSON ROAD WOODBURY MN 55125
2429226 SHOPKO PHARMACY 5630 ST CROIX TRAIL NORTH BRANCH MN 55056-4202
2419756 CVS PHARMACY # 8655 E POINT DOUGLAS RD S COTTAGE GROVE MN 55016
2418122 WALGREENS #15560 2700 LINCOLN DR ROSEVILLE MN 55113
2428452 CVS PHARMACY 2730 COUNTRY ROAD EAST WHITE BEAR LAKE MN 55110
2425773 CUB PHARMACY 3717 LEXINGTON AVE N ARDEN HILLS MN 55126
2430522 CVS PHARMACY # 449 COMMERCE DR WOODBURY MN 55125
2423337 FAIRVIEW SPECIALTY SERVICES PHARMAC711 KASOTA AVENUE SOUTHEAST MINNEAPOLIS MN 55414
2421030 CUB PHARMACY 1059 MEADOWLANDS DR WHITE BEAR LAKE MN 55127
2401141 GUERTIN PHARMACY 21 CENTURY AVE S MAPLEWOOD MN 55119-5202
2429098 COSTCO PHARMACY 1431 BEAM AVE MAPLEWOOD MN 55109
2422450 WALGREENS #4038 15034 SHANNON PKWY ROSEMOUNT MN 55068
2424353 SAMS PHARMACY 10-6309 1850 BUERKLE ROAD WHITE BEAR LAKE MN 55110
2427183 CVS PHARMACY 1040 GRAND AVE ST PAUL MN 55105
5126948 HUDSON HOSPITAL & CLINIC 405 STAGELINE RD HUDSON WI 54016
2402270 MEDICINE CHEST PHARMACY INC. 2187 4TH STREET WHITE BEAR LAKE MN 55110-3094
2426624 LUNDS & BYERLYS PHARMACY #1013 1299 PROMENADE PLACE EAGAN MN 55121
5128574 WALMART PHARMACY 10-5432 250 WEST RICHMOND WAY NEW RICHMOND WI 54017
2400202 WALGREENS 1550 UNIVERSITY AVE W ST PAUL MN 55104-3908
2424517 WALGREENS #6735 3700 SILVER LAKE RD NE SAINT ANTHONY MN 55421
2424670 CUB PHARMACY 2013 BROADWAY AVE W FOREST LAKE MN 55025
2425634 CVS PHARMACY # 1500 109TH AVE NE BLAINE MN 55449
2428426 CVS PHARMACY # 6445 RICHFIELD PKWY RICHFIELD MN 55423
2432689 FAIRVIEW PHARMACY CHISAGO CITY 11725 STINSON AVE BLDG B CHISAGO CITY MN 55013-9542
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
3 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
5129778 WALGREENS #10585 1047 N MAIN ST RIVER FALLS WI 54022-1596
2427652 CVS PHARMACY # 755 53RD AVE NE FRIDLEY MN 55421
2423438 WALGREENS #5048 1017 VERMILLION ST HASTINGS MN 55033-2898
2428779 CVS PHARMACY 1471 ROBERT ST WEST SAINT PAUL MN 55118
2429795 CVS PHARMACY # 2650 RICE ST. LITTLE CANADA MN 55117
2420507 WALGREENS #2766 2010 CLIFF ROAD EAGAN MN 55122
2426181 CVS PHARMACY 4241 JONNY CAKE RD EAGAN MN 55122
2425610 WALGREENS #7781 4202 PHEASANT RIDGE DR NE BLAINE MN 55449
2422309 MERWIN LONG TERM CARE PHARMACY 1509 10TH AVE SOUTH MINNEAPOLIS MN 55404
2418514 HEALTHPARTNERS RIVERSIDE PHARMACY 2220 RIVERSIDE AVE S MINNEAPOLIS MN 55454-1439
2404286 CVS PHARMACY # 3300 124TH AVE NW COON RAPIDS MN 55433
2417409 WALGREENS #10641 1274 TOWNE CENTRE DR EAGAN MN 55123
2423476 ALLINA HEALTH WOODBURY PHARMACY 8675 VALLEY CREEK RD WOODBURY MN 55125
2411813 HEALTHPARTNERS BROOKLYN CENTER PH 6845 LEE AVE N BROOKLYN CENTER MN 55429-1799
2419782 CUB PHARMACY 2001 S ROBERT ST WEST ST PAUL MN 55118
2427501 LAKEVIEW COMMUNITY PHARMACY 1500 CURVE CREST BLVD STILLWATER MN 55082
2425987 LUNDS & BYERLYS PHARMACY #51007 2128 FORD PKWY ST PAUL MN 55116
2423515 FAIRVIEW LAKES PHARMACY LINO LAKES 7455 VILLAGE DRIVE LINO LAKES MN 55014
2400632 HOPKINS CENTER DRUG INC 913 HOPKINS CENTER HOPKINS MN 55343
2432451 CUB PHARMACY 1201 LARPENTEUR AVE W ROSEVILLE MN 55113
5122130 SHOPKO PHARMACY 1777 PAULSON RD RIVER FALLS WI 54022-8299
2432994 TOTAL CARE PHARMACY 7221 UNIVERSITY AVE FRIDLEY MN 55432
2414162 WYOMING DRUG 26710 FOREST BLVD WYOMING MN 55092-9324
2420367 WALMART PHARMACY 10-1786 1360 TOWN CENTRE DRIVE EAGAN MN 55123
2421698 CUB PHARMACY 1440 UNIVERSITY ST PAUL MN 55104
2432918 HY-VEE PHARMACY (1462) 7180 10TH ST N OAKDALE MN 55128-1122
2426662 WALMART PHARMACY 10-3404 1960 TWIN LAKES PKWY ROSEVILLE MN 55113-1324
2426814 WALGREENS #7728 17630 KENWOOD TRL LAKEVILLE MN 55044
2429480 THRIFTY WHITE PHARMACY #773 1420 LAKE ST S STE 100 FOREST LAKE MN 55025-2714
2429783 FAIRVIEW PHARMACY HUGO 14712 VICTOR HUGO BLVD N STE 10 HUGO MN 55038-4561
2432095 WALMART PHARMACY 10-2448 9300 EAST POINT DOUGLAS RD S COTTAGE GROVE MN 55016
2419097 WALGREENS #4119 4547 HIAWATHA MINNEAPOLIS MN 55406
2424581 LAKEVIEW OUTPATIENT PHARMACY 927 W CHURCHILL STREET STILLWATER MN 55082
2417574 CUB PHARMACY 8690 E PT DOUGLAS RD COTTAGE GROVE MN 55016
2431586 WALMART PHARMACY 10-5977 12200 RIVER RIDGE BLVD BURNSVILLE MN 55337-1608
2431877 FAIRVIEW PHARMACY NORTH BRANCH 5366 386TH ST NORTH BRANCH MN 55056
2419960 WALGREENS #2661 15250 CEDAR AVE APPLE VALLEY MN 55124
2401836 WALGREENS 7700 BROOKLYN BLVD BROOKLYN PARK MN 55443-2906
2424567 WALGREENS #5634 7560 160TH ST WEST LAKEVILLE MN 55044
2420785 WALGREENS 16395 WAGNER WAY EDEN PRAIRIE MN 55344
2423060 WALGREENS #4879 8100 W COUNTY ROAD 42 SAVAGE MN 55378-2193
2419807 WALGREENS #2496 14700 LAC LAVON DR BURNSVILLE MN 55306
2421369 CVS PHARMACY # 2021 MARKET DR STILLWATER MN 55082
2431942 WALMART PHARMACY 10-5976 11505 ULYSSES ST NE BLAINE MN 55434-4239
2417699 WALGREENS 2860 COON RAPIDS BLVD NW COON RAPIDS MN 55433
2418590 WALGREENS #16057 5428 LYNDALE AVE S MINNEAPOLIS MN 55419
2417372 CVS PHARMACY # 6100 SHINGLE CREEK PKWY BROOKLYN CENTER MN 55430
2432829 CVS PHARMACY # 2080 FORD PKWY SAINT PAUL MN 55116
2422056 ALLINA HEALTH COTTAGE GROVE PHARMA8611 W POINT DOUGLAS RD SOUTH COTTAGE GROVE MN 55016
2430003 WALGREENS #13938 135 E BROADWAY ST MONTICELLO MN 55362-8791
2425038 CVS PHARMACY # 18275 KENRICK AVE LAKEVILLE MN 55044
2408436 WEST SEVENTH PHARMACY 1106 W 7TH ST ST PAUL MN 55102
2423630 WALGREENS #5685 2200 HWY 13 E BURNSVILLE MN 55337
2424442 CVS PHARMACY # 900 NICOLLET MALL MINNEAPOLIS MN 55403
2429199 THRIFTY WHITE PHARMACY #772 707 LUNDORFF DRIVE SANDSTONE MN 55072
2422311 WALMART PHARMACY 10-2367 950 11TH ST SW PINE CITY MN 55063-2001
2420610 HEALTHPARTNERS COON RAPIDS PHARMA11475 ROBINSON DR NW COON RAPIDS MN 55433-7432
2421977 CUB PHARMACY 8432 TAMARACK VILLAGE WOODBURY MN 55125
2423779 WALGREENS #5413 600 HWY 10 NE BLAINE MN 55434
2424404 CUB PHARMACY 3784 150TH ST ROSEMOUNT MN 55068
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
4 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2426674 CVS PHARMACY # 2000 BUNKER LAKE BLVD NW ANDOVER MN 55304
2400226 WALGREENS #4260 540 BLAKE RD N HOPKINS MN 55343
2417788 WALGREENS 2610 CENTRAL AVE NE MINNEAPOLIS MN 55418-2911
2430724 FAIRVIEW PHARMACY LONG TERM CARE 711D KASOTA AVE SE MINNEAPOLIS MN 55414
2417687 WALGREENS #16279 3121 E LAKE ST MINNEAPOLIS MN 55406
2418564 CVS PHARMACY # 2000 CLIFF LAKE RD EAGAN MN 55122
2432398 CUB PHARMACY 892 ARCADE STREET SAINT PAUL MN 55106
2428692 CVS PHARMACY # 15560 PILOT KNOB RD APPLE VALLEY MN 55124
2428666 WALGREENS #11287 10905 UYLSSES ST NE BLAINE MN 55434-3801
2411039 HCMC P 1 PHARMACY 701 PARK AVE S MINNEAPOLIS MN 55415
2428488 CVS PHARMACY 19605 PILOT KNOB RD FARMINGTON MN 55024
2422703 WALGREENS #4697 6525 UNIVERSITY AV NE FRIDLEY MN 55432
2420999 WALGREENS #3114 6975 YORK AVE S EDINA MN 55435
2431447 ALIXARX - MN HUB 10132 W 76TH ST EDEN PRAIRIE MN 55344-3728
2426333 WALGREENS #2078 2134 BUNKER LAKE BLVD NW ANDOVER MN 55304
5119599 OMNICARE OF MILWAUKEE 5185 S NINTH ST MILWAUKEE WI 53221
2425797 WALMART PHARMACY 10-5089 9165 CAHILL AVENUE INVER GROVE HEIGHTS MN 55076
2417904 MAYO CLINIC PHARMACY BRACKENRIDGE BUILDING ROCHESTER MN 55902-3026
2422323 WALGREENS #4320 6390 BROOKLYN BLVD BROOKLYN CENTER MN 55429
2431497 WALMART PHARMACY 10-5625 1200 SHINGLE CREEK CROSSING BROOKLYN CENTER MN 55430
5110779 YELLOW RIVER PHARMACY INC 7438 MAIN ST WEST WEBSTER WI 54893
2401925 CVS PHARMACY # 7000 YORK AVE S EDINA MN 55435
2415328 HEALTHPARTNERS WEST PHARMACY 5100 GAMBLE DR STE 100 ST LOUIS PARK MN 55416
0000099
0323624 WALGREENS #5823 8350 S RIVER PKWY TEMPE AZ 85284
5119602 WALMART PHARMACY 10-1365 2222 CREST VIEW DRIVE HUDSON WI 54016
5121253 MAYO CLINIC HEALTH SYSTEM PHARMACY 733 W CLAIREMONT AVE EAU CLAIRE WI 54701-6101
2420040 WALGREENS #16361 2650 HENNEPIN AVE MINNEAPOLIS MN 55408-1149
5123803 COUNTY MARKET PHARMACY 2310 CRESTVIEW DR HUDSON WI 54016
2427171 WALGREENS #9727 14020 PILOT KNOB RD APPLE VALLEY MN 55124
2426989 WALMART PHARMACY 10-2643 10240 HUDSON ROAD WOODBURY MN 55129
2427068 CVS PHARMACY 2150 EAGLE CREEK LN WOODBURY MN 55129
2413134 HEALTHPARTNERS BLOOMINGTON PHARM 8600 NICOLLET AVE S BLOOMINGTON MN 55420
2425824 LUNDS & BYERLYS PHARMACY #1008 13081 RIDGEDALE DRIVE MINNETONKA MN 55305
2412358 REGIONS HOSPITAL PHARMACY 640 JACKSON ST ST PAUL MN 55101-2502
2415366 HEALTHPARTNERS APPLE VALLEY PHARMA15290 PENNOCK LN APPLE VALLEY MN 55124-7163
2417512 CUB PHARMACY 585 NORTHTOWN DR NE BLAINE MN 55434
2418362 WALGREENS #4394 9800 LYNDALE AVE S BLOOMINGTON MN 55420
2424264 CUB PHARMACY 2600 RICE CREEK RD NEW BRIGHTON MN 55112
2419617 PARK NICOLLET PHARMACY ST LOUIS PAR3850 PARK NICOLLET BLVD ST LOUIS PARK MN 55416
0416087 THOMAS LAKESIDE PHARMACY 902 CENTRAL BLVD BULL SHOALS AR 72619
2421939 FAIRVIEW HIGHLAND PARK PHARMACY 2155 FORD PARKWAY ST PAUL MN 55116
2422133 CUB PHARMACY 12595 CENTRAL AVE NE BLAINE MN 55434
2422183 THRIFTY NYSTROM DRUG #738 223 SOUTH EIGHTH STREET BRAINERD MN 56401
2430736 PHALEN FAMILY PHARMACY LTD 1001 JOHNSON PKWY STE B23 SAINT PAUL MN 55106-3474
2400074 WALGREENS #13877 1131 E SUPERIOR ST DULUTH MN 55802
5132600 OSCEOLA CLINIC PHARMACY 2600 65TH AVE OSCEOLA WI 54020
2426408 CVS PHARMACY 6300 WEDGEWOOD RD N MAPLE GROVE MN 55311
2412601 CVS PHARMACY # 810 COUNTY RD 42 W BURNSVILLE MN 55337
2411508 MINNEAPOLIS VAMC PHARMACY 1 VETERANS DR MINNEAPOLIS MN 55417
2418502 ALLINA HEALTH UNITED PHARMACY 333 SMITH AVE N SAINT PAUL MN 55102-2344
2428767 CVS PHARMACY 1110 HENNEPIN AVE MINNEAPOLIS MN 55403
2412562 MELROSE PHARMACY 611 W MAIN ST MELROSE MN 56352
2429202 CUB PHARMACY 1177 CLARENCE ST SAINT PAUL MN 55106
2416976 WALGREENS #1303 4323 CHICAGO MINNEAPOLIS MN 55407
2424290 CUYUNA LAKES PHARMACY 320 E MAIN ST CROSBY MN 56441
2420216 WALGREENS #11419 950 COUNTY ROAD 42 W BURNSVILLE MN 55337-4428
5122229 SHOPKO PHARMACY 320 S ACCESS RD RICE LAKE WI 54868-8572
3061582 PILLPACK PHARMACY 250 COMMERCIAL ST STE 2012 MANCHESTER NH 03101-1142
2424505 CUB PHARMACY 4205 PHEASANT RIDGE DR BLAINE MN 55449
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
5 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
5134488 ST CROIX FALLS PHARMACY 216 S ADAMS STREET ST CROIX FALLS WI 54024
2426105 WALGREENS #2460 115 GARFIELD ST N CAMBRIDGE MN 55008
5130606 SHOPKO PHARMACY #2512 598 LUCAS LANE ELLSWORTH WI 54011
2426321 LUNDS & BYERLYS PHARMACY #51002 3945 W 50TH ST EDINA MN 55424
2432146 TAREEN DERMATOLOGY PA 1835 COUNTY ROAD C W STE 250 ROSEVILLE MN 55113-1311
2416964 WALGREENS #7188 4880 CENTRAL AVE NE HILLTOP MN 55421
2422931 WALMART PHARMACY 10-2642 7835 150TH ST WEST APPLE VALLEY MN 55124
2405101 ALLINA HEALTH UNITY PHARMACY 550 OSBORNE RD FRIDLEY MN 55432
2420646 WALMART PHARMACY 10-1472 1752 N FRONTAGE RD HASTINGS MN 55033-3490
5120150 WALMART PHARMACY 10-1446 2501 WEST AVENUE RICE LAKE WI 54868
2432970 CUB PHARMACY 1920 BUERKLE RD WHITE BEAR LAKE MN 55110
0319257 WALGREENS #03669 10324 E RIGGS ROAD SUN LAKES AZ 85248-7625
2425622 CVS PHARMACY # 11990 BUSINESS PARK BLVD N CHAMPLIN MN 55316
2427056 ALLINA HEALTH APPLE VALLEY PHARMACY14655 GALAXIE AVE APPLE VALLEY MN 55124
2427664 CVS PHARMACY 4152 LAKELAND AVE N ROBBINSDALE MN 55422
2428387 THRIFTY WHITE PHARMACY #768 183 N TYLER ST TYLER MN 56178
1617010 WALMART PHARMACY 10-0581 2802 S CENTER STREET MARSHALLTOWN IA 50158
4541252 DAVITA RX 1234 LAKESHORE DR COPPELL TX 75019
2426345 COSTCO PHARMACY 12011 TECHNOLOGY DRIVE EDEN PRAIRIE MN 55344
2432285 FIRSTLIGHT HEALTH SYSTEM PHARMACY 1425 MAIN ST N PINE CITY MN 55063
5121811 WALGREENS #3064 2015 TOWER AVENUE SUPERIOR WI 54880
5113054 FAMILY FRESH MARKET PHARMACY 110 WEST 4TH STREET NEW RICHMOND WI 54017
5126049 FAMILY FRESH MARKET PHARMACY 2351 COULEE ROAD HUDSON WI 54016
2426410 CVS PHARMACY 3655 CENTRAL AVE NE MINNEAPOLIS MN 55418
2400694 CVS PHARMACY # 2555 W 79TH ST BLOOMINGTON MN 55431
2428503 LAKE ELMO PHARMACY 11240 STILLWATER BLVD N LAKE ELMO MN 55042-9640
5113701 LUCK PHARMACY 132 S MAIN ST LUCK WI 54853
2421648 CUB PHARMACY 5937 NICOLLET AVE MINNEAPOLIS MN 55419
2419566 WALMART PHARMACY 10-1632 4611 HWY 29 SO ALEXANDRIA MN 56308
2423919 COSTCO PHARMACY 5801 16TH ST W ST LOUIS PARK MN 55416
2427765 CVS PHARMACY 15051 GALAXIE APPLE VALLEY MN 55124
2402915 ROLSETH DRUG CO 107 LAKE ST N FOREST LAKE MN 55025-2594
2638154 WALGREENS 106 SILVER THREAD LN BRANSON WEST MO 65737
1053949 WALMART PHARMACY 10-0956 1001 EAST EAU GALLIE BLVD INDIAN HARBOR BEACH FL 32937
2423010 WALGREENS #4725 11401 MARKET PLACE RD CHAMPLIN MN 55316-3794
2421561 CUB PHARMACY 5301 36TH AVE N CRYSTAL MN 55422
2433364 CVS PHARMACY # 30 FAIRVIEW AVE S SAINT PAUL MN 55105-1463
2426395 CVS PHARMACY 2357 108TH LANE NE BLAINE MN 55449
2426078 WALGREENS #2316 2024 85TH AVE N BROOKLYN PARK MN 55444
0425656 WALMART PHARMACY 10-5790 1544 MALVERN AVE HOT SPRINGS AR 71901-6535
2424012 WALGREENS #6489 1291 TASHA DRIVE SHAKOPEE MN 55379
2431992 WALMART PHARMACY 10-1999 1851 BUNKER LAKE BLVD NW ANDOVER MN 55304-4010
5109637 TANGEN DRUG INC 124 N WASHINGTON ST ST CROIX FALLS WI 54024
2422690 MN CANCER CARE PHARMACY 1580 BEAM AVE MAPLEWOOD MN 55109
2431194 GUARDIAN PHARMACY OF MINNESOTA 940 INDUSTRIAL DR S SAUK RAPIDS MN 56379-1235
2422640 CVS PHARMACY # 15300 GROVE CIRCLE N MAPLE GROVE MN 55369
5134301 FREDERIC PHARMACY 201 OAK STREET WEST FREDERIC WI 54837
2421941 FAIRVIEW NORTHLAND PHARMACY PRINC 919 NORTHLAND DRIVE PRINCETON MN 55371
2424175 WALGREENS #6573 3470 RIVER RAPIDS DR NW COON RAPIDS MN 55448
2426509 CVS PHARMACY 2800 COUNTY RD 10 MOUNDS VIEW MN 55112
2431687 SPRING PARK PHARMACY 4689 SHORELINE DR STE 100 SPRING PARK MN 55384-9715
2429048 FAIRVIEW PHARMACY BROOKLYN PARK 10000 ZANE AVE NORTH BROOKLYN PARK MN 55443
2416724 WALGREENS #13853 4950 COUNTY RD 101 MINNETONKA MN 55345
2423286 STERLING 1399 S FRONTAGE RD HASTINGS MN 55033
5127407 OMNICARE OF LACROSSE 3235 AIRPORT RD LA CROSSE WI 54603
2419023 FAIRVIEW EDINA PHARMACY 6363 FRANCE AVENUE SOUTH EDINA MN 55435
2419213 CVS PHARMACY # 15150 CEDAR AVE APPLE VALLEY MN 55124
5105110 VILLAGE PHARMACY 840 MAIN ST BALDWIN WI 54002
2428630 WALGREENS #11916 1221 WEST LAKE ST MINNEAPOLIS MN 55408-3397
2430065 CVS PHARMACY # 1010 W. LAKE ST MINNEAPOLIS MN 55408-2860
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
6 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2431613 CVS PHARMACY # 12751 NICOLLET AVE BURNSVILLE MN 55337-2896
2428349 FOND DU LAC MASHKIKI WAAKAAIGAN PH2020 BLOOMINGTON AVE MINNEAPOLIS MN 55404
2431740 CVS PHARMACY # 2420 DIVISION ST ST. CLOUD MN 56301
2420305 GERITOM MED INC 10501 FLORIDA AVE SO BLOOMINGTON MN 55438
2419352 GOODRICH PHARMACY ELK RIVER 530 3RD ST ELK RIVER MN 55330-1426
2422866 CUB PHARMACY 1198 VIERLING DR SHAKOPEE MN 55379
2423096 FAIRVIEW EAGAN PHARMACY 3305 CENTRAL PARK VILLAGE DR EAGAN MN 55121-7707
2424149 CHILDREN'S HOSPITAL AND CLINICS 345 N SMITH AVE ST PAUL MN 55102
2431219 SHOPKO PHARMACY 611 1002 OLD MINNESOTA AVE SAINT PETER MN 56082-2023
2422563 MAYO CLINIC PHARMACY NORTHWEST 4111 WEST FRONTAGE RD HWY 52 NW ROCHESTER MN 55901
2418463 WALGREENS #13607 4100 W BROADWAY AVE ROBBINSDALE MN 55422
2430180 UNITED COMMUNITY PHARMACY CORPORA2500 NEW BRIGHTON BLVD. SAINT ANTHONY MN 55418
5106275 MICKLESEN DRUG INC 530 2ND ST HUDSON WI 54016
2426319 CVS PHARMACY 3633 BUNKER LAKE BLVD NW ANDOVER MN 55304
2431435 CVS PHARMACY # 7841 AMANA TRAIL INVER GROVE HEIGHTS MN 55077
2817130 MIDWEST LTC PHARMACY 3003 FRONTAGE ROAD GRAND ISLAND NE 68803
2417916 CVS PHARMACY # 3601 HIGHWAY 100 S ST LOUIS PARK MN 55416
2428591 FAIRVIEW COLUMBIA HEIGHTS PHARMACY4000 CENTRAL AVE NE COLUMBIA HEIGHTS MN 55421
1093424 WALGREENS #5641 3425 53RD AVE WEST BRADENTON FL 34210
2428351 SEIP DRUG 113 LAKE AVE N BATTLE LAKE MN 56515-0538
2429872 GENOA, A QOL HEALTHCARE COMPANY, LL1900 SILVER LAKE RD NW STE 111 NEW BRIGHTON MN 55112
2429478 WALGREENS #12131 1301 1ST ST S WILLMAR MN 56201-4201
2419340 WALMART PHARMACY 10-1562 13020 RIVERDALE DRIVE COON RAPIDS MN 55448
2421725 WALMART PHARMACY 10-2352 2101 SECOND AVENUE SE CAMBRIDGE MN 55008
2426167 LUNDS & BYERLYS PHARMACY #51008 1151 WAYZATA BLVD WAYZATA MN 55391
2432449 CUB PHARMACY 17756 KENWOOD TRAIL LAKEVILLE MN 55044
2424935 WALGREENS #6730 1511 HIGHWAY 7 HOPKINS MN 55305
2429214 CVS PHARMACY 8251 COLUMBINE RD EDEN PRAIRIE MN 55344
2415467 WEBER & JUDD - BARLOW PLAZA 1315 SIXTH ST NW ROCHESTER MN 55901-1824
2422498 HY-VEE PHARMACY (1177) 1920 GRANT STREET FARIBAULT MN 55021
2429670 WALGREENS #11250 3913 W OLD SKAKOPEE RD BLOOMINGTON MN 55437
5104966 CHET JOHNSON DRUGS INC 204 N KELLER AVE AMERY WI 54001
0317164 WALGREENS #2398 925 WEST BASELINE STE 108 TEMPE AZ 85283
0323826 WALGREENS #5392 420 S SOSSAMAN RD MESA AZ 85208
2422359 CVS PHARMACY # 1650 NEW BRIGHTON BLVD MINNEAPOLIS MN 55413
4927248 WALGREENS #04730 13110 BOTHELL EVERETT HWY EVERETT WA 98208
2413615 KMART PHARMACY3059 245 E MARYLAND AVE ST. PAUL MN 55117
2422157 RX EXPRESS 8400 CORAL SEA ST NE MOUNDS VIEW MN 55112
2401886 GOODRICH PHARMACY INC 601 JACOB LANE ANOKA MN 55303-2488
2409995 ESSENTIA HEALTH DL PHARMACY 211 FRAZEE ST EAST DETROIT LAKES MN 56501
2418691 PARK NICOLLET PHARMACY MEADOWBROO3931 LOUISIANA AVE S ST LOUIS PARK MN 55426
2427931 WALGREENS #1479 16750 CTY RD 30 MAPLE GROVE MN 55311-4523
2429303 CUB PHARMACY 1020 DIFFLEY ROAD EAGAN MN 55123
2430990 WALGREENS 5033 VERNON AVE S EDINA MN 55436-2102
2406571 PARK NICOLLET PHARMACY MINNEAPOLIS2001 BLAISDELL AVENUE SOUTH MINNEAPOLIS MN 55404
2410164 CVS PHARMACY # 2500 E LAKE ST MINNEAPOLIS MN 55406
2423844 CVS PHARMACY # 215 BALSAM ST N CAMBRIDGE MN 55008
3973864 RITE AID PHARMACY 04988 9920 BUSTLETON AVENUE PHILADELPHIA PA 19115-2149
2415556 MEDSAVE FAMILY PHARMACY 217 PAUL BUNYAN DR NW BEMIDJI MN 56601
2419706 WALGREENS 4916 FRANCE AVE S EDINA MN 55410
0316287 WALMART PHARMACY 10-1299 2003 E RODEO DRIVE COTTONWOOD AZ 86326
2420862 CROSSLAKE DRUG 14311 GOULD ST. CROSSLAKE MN 56442-0578
2431788 WALGREENS 2251 COMMERCE BLVD MOUND MN 55364-1546
2406785 PHARMERICA 5255 E RIVER RD FRIDLEY MN 55421
2414910 CVS PHARMACY # 13201 RIDGEDALE DR MINNETONKA MN 55305
2422715 FAIRVIEW HIAWATHA PHARMACY 3809 42ND AVE S MINNEAPOLIS MN 55406
2429442 WALGREENS #12510 6025 SHENANDOAH LN N PLYMOUTH MN 55446
2415657 THOMPSONS LAKE COUNTRY DRUG INC 205 MAIN ST W ISLE MN 56342
2424707 CUB PHARMACY 2100 SNELLING AVE N ROSEVILLE MN 55113
5117898 WALMART PHARMACY 10-0965 222 WEST MCCOY BLVD TOMAH WI 54660
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
7 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2411178 ALLINA HEALTH PHILLIPS EYE INSTITUTE 2215 PARK AVE SOUTH MINNEAPOLIS MN 55404-3711
2418209 WALGREENS #16275 655 NICOLLET MALL MINNEAPOLIS MN 55402
4303703 SAFEWAY PHARMACY #0581 2120 MOUNT RUSHMORE RD RAPID CITY SD 57701
5130428 SOMERSET DRUG 107 PARENT STREET SOMERSET WI 54025
1471781 CVS PHARMACY 753 WEST HWY 50 OFALLON IL 62269
2403652 MOONS PHARMACY 17 MAIN ST S BLACKDUCK MN 56630
2425850 CUB PHARMACY 7435 179TH ST LAKEVILLE MN 55044
2432350 CVS PHARMACY # 1329 5TH STREET SE MINNEAPOLIS MN 55414
3810606 OMNICARE OF PORTLAND 11933 NE GLENN WIDING DR PORTLAND OR 97220
1529239 CVS PHARMACY #06570 2800 ENTERPRISE INDIANAPOLIS IN 46219
2426888 CVS PHARMACY 7765 GALPIN BLVD CHANHASSEN MN 55317
3210743 SAMS PHARMACY 10-4784 2711 N. TELSHOR BLVD LAS CRUCES NM 88011-8202
2417219 ALLINA HEALTH MERCY PHARMACY 11850 BLACKFOOT STREET, NW COON RAPIDS MN 55433
2420115 CVS PHARMACY # 7535 W BROADWAY AVE BROOKLYN PARK MN 55428
2430332 COSTCO WHOLESALE #1087 14050 BURNHAVEN DR BURNSVILLE MN 55337
0313356 WALGREENS #5208 25 LAKE HAVASU AVE S LAKE HAVASU CITY AZ 86403
2402092 NEWPORT DRUGS INC 1644 HASTINGS AVE NEWPORT MN 55055-9593
2424365 SAMS PHARMACY 10-6310 8150 UNIVERSITY AVE NE FRIDLEY MN 55432
2427981 CVS PHARMACY # 1447 E 7TH ST MONTICELLO MN 55362
2408955 MACKENTHUN BECK PHARMACY INC 851 MARKETPLACE DR WACONIA MN 55387
2413499 MINNESOTA VETERANS HOME PHARMACY 5101 MINNEHAHA AVENUE MINNEAPOLIS MN 55417-1647
2420406 WALGREENS #2767 4005 VINEWOOD LANE PLYMOUTH MN 55442
2424252 CVS PHARMACY # 3827 MARKETPLACE DR NW ROCHESTER MN 55901
4532203 CVS PHARMACY 4426 WILLIAMS DR GEORGETOWN TX 78628-1341
2420317 CVS PHARMACY # 8600 SPRINGBROOK DR NW COON RAPIDS MN 55433
2428868 WALGREENS 121 DEPOT DR WACONIA MN 55387
5701001 PUBLIX PHARMACY #1373 16041 TAMPA PALMS BLVD WEST TAMPA FL 33647
0316910 WALGREENS #06582 9230 E MAIN ST MESA AZ 85207-8803
1303293 KMART PHARMACY7033 1815-21ST ST LEWISTON ID 83501
2433566 HY-VEE PHARMACY (1090) 7280 E POINT DOUGLAS RD S COTTAGE GROVE MN 55016
0326214 WALGREENS #6333 2440 S IRONWOOD DR APACHE JUNCTION AZ 85120-7652
2418146 TRUMM DRUG GLENWOOD 7 FOURTH AVE SE GLENWOOD MN 56334
5134515 HEALTHDIRECT INSTITUTIONAL PHARMAC 3184 LONDON RD EAU CLAIRE WI 54701-6834
2422652 ALLINA HEALTH CAMBRIDGE PHARMACY 701 S DELLWOOD ST CAMBRIDGE MN 55008
3845914 FRED MEYER PHARMACY #694 17005 SE SUNNYSIDE RD HAPPY VALLEY OR 97015-8724
0328244 WALGREENS #6880 2431 S HIGLEY RD GILBERT AZ 85295-1100
1013084 CVS PHARMACY 11300 STATE ROAD 82 FORT MYERS FL 33905
2406987 COBORNS PHARMACY #2017 710 FRANKIE LANE MORA MN 55051
2409983 FAIRVIEW RIVERSIDE PHARMACY 606 24TH AVENUE SOUTH MINNEAPOLIS MN 55454
2414883 THRIFTY WHITE PHARMACY #037 211 MARKET DR, SUITE C PERHAM MN 56573-1701
2429543 CUB PHARMACY 10520 FRANCE AVE SOUTH BLOOMINGTON MN 55431
2637164 WALGREENS 3497 TECHNOLOGY DR LAKE ST LOUIS MO 63367-2599
5103546 FREEMAN DRUG 104 S MAIN ST RIVER FALLS WI 54022-2496
0324385 WALMART PHARMACY 10-2777 13770 WEST BELL ROAD SURPRISE AZ 85374
2427640 CVS PHARMACY # 8900 HWY 7 MINNEAPOLIS MN 55426
2428464 CUB PHARMACY 20250 HERITAGE DR LAKEVILLE MN 55044
2430433 WALGREENS #15679 1055 E WAYZATA BLVD WAYZATA MN 55391-1952
2988814 WALGREENS #02474 3000 VISTA BLVD SPARKS NV 89436
3807635 RITE AID PHARMACY 05374 1970 ECHO HOLLOW ROAD EUGENE OR 97402-1394
2421460 THE MEDICINE SHOPPE PHARMACY 750 MAIN ST # 103 MENDOTA HEIGHTS MN 55118
2423539 WALGREENS #5325 3110 CHASKA BLVD CHASKA MN 55318
2429694 WALGREENS #12404 3141 S SERVICE DR RED WING MN 55066-1943
3462265 HARRIS TEETER PHARMACY #204 8538 PARK ROAD CHARLOTTE NC 28210
3211101 CVS PHARMACY # 6100 PASEO DEL NORTE NE ALBUQUERQUE NM 87113
0326062 CVS PHARMACY # 1225 W IRVINGTON RD TUCSON AZ 85714
5106047 WOOD RIVER PHARMACY 122 W MADISON AVE GRANTSBURG WI 54840-0039
0354655 WALMART PHARMACY 10-4325 8151 EAST 32ND STREET YUMA AZ 85365
2637974 WALMART PHARMACY 10-4381 1101 BRANSON HILLS P BRANSON MO 65616
5728831 RXPERTS HOLLYWODD-POLARIS RX 2900 NW 60TH ST FORT LAUDERDALE FL 33309-1735
2405240 GLOBE DRUG AND MEDICAL EQUIPMENT 304 N POKEGAMA AVE GRAND RAPIDS MN 55744-2745
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
8 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2421636 CVS PHARMACY # 15800 87TH ST NE OTSEGO MN 55330
2423591 WALGREENS #5635 340 W WASHINGTON ST BRAINERD MN 56401
0313065 WALGREENS #4344 1514 E FLORENCE BLVD CASA GRANDE AZ 85122-4741
2425646 CVS PHARMACY # 14333 HIGHWAY 13 S SAVAGE MN 55378
2432348 WALMART PHARMACY 10-4849 8580 ROCK RIDGE DR MOUNTAIN IRON MN 55768
2401848 WALGREENS #430 5695 DULUTH ST GOLDEN VALLEY MN 55422
2411104 BOYNTON HEALTH PHARMACY 410 CHURCH STREET SE, N300 MINNEAPOLIS MN 55455-0346
1141364 CVS PHARMACY 30 MARKET STREET ST SIMONS ISLAND GA 31522
2426749 ALLINA HEALTH HEART HOSPITAL PHARMA920 E 28TH ST MINNEAPOLIS MN 55407
2427777 CVS PHARMACY 5696 UNIVERISTY AVE FRIDLEY MN 55432
2429947 WALGREENS #12972 100 CHALUPSKY AVE NE NEW PRAGUE MN 56071-6820
0320971 COSTCO PHARMACY 17550 N 79TH AVE GLENDALE AZ 85308
0319079 WALGREENS #2599 7337 PASEO DEL SUR SCOTTSDALE AZ 85258
2431310 CVS PHARMACY # 2323 HIGHWAY 3 S NORTHFIELD MN 55057
2989309 WALMART PHARMACY 10-3729 5065 PYRAMID LAKE ROAD SPARKS NV 89436
1025318 WALGREENS #10373 2235 PARR DR LADY LAKE FL 32162-5381
1043188 WALGREENS 15601 SAN CARLOS BLVD FORT MYERS FL 33908-2570
1084451 WALGREENS #4708 35800 HWY 27 HAINES CITY FL 33844
2420963 CVS PHARMACY # 851 W 78TH ST CHANHASSEN MN 55317
2424694 WALMART PHARMACY 10-3498 4369 BALL RD NE BLAINE MN 55449
2416128 WALGREENS #15983 627 WEST BROADWAY MINNEAPOLIS MN 55411
2430356 GOODRICH PHARMACY FRIDLEY 480 OSBORNE RD NE FRIDLEY MN 55432-2608
2432627 CVS PHARMACY # 1411 VERMILLION ST HASTINGS MN 55033-2844
5119195 WALMART PHARMACY 10-1277 611 HWY 54 EAST BLACK RIVER FALLS WI 54615
2421410 FAIRVIEW SOUTHDALE MEDICAL PHARMA 6545 FRANCE AVENUE SOUTH EDINA MN 55435
0421165 HARPS PHARMACY 135 924 EAST HIGHWAY 62 MOUNTAIN HOME AR 72653
2429822 CVS PHARMACY 7996 BROOKLYN BLVD BROOKLYN PARK MN 55445-2722
3424277 WALMART PHARMACY 10-1097 250 TURNER STREET ABERDEEN NC 28315
2419643 PARK NICOLLET PHARMACY CARLSON 15111 TWELVE OAKS CENTER DRIVE MINNETONKA MN 55305
2422955 CUB PHARMACY 1008 HWY 55 E BUFFALO MN 55313
2423325 THRIFTY WHITE PHARMACY 241 W HWY 210 MCGREGOR MN 55760
2424341 SAMS PHARMACY 10-4738 3035 DENMARK AVENUE EAGAN MN 55121
2425280 THRIFTY WHITE DRUG #748 603 W MINNESOTA AVENUE WEST WALKER MN 56484
5121330 MAYO CLINIC HEALTH SYSTEM-PHARM & H1400 BELLINGER ST EAU CLAIRE WI 54703
2409414 ZUMBROTA MAIN STREET PHARMACY 370 MAIN ST ZUMBROTA MN 55992
2429771 CVS PHARMACY # 949 PORTLAND AVE MINNEAPOLIS MN 55404-1192
0133784 CVS PHARMACY # 3820 GULF SHORES PKWY GULF SHORES AL 36542
0422066 WALMART PHARMACY 10-5433 3604 NORTH HIGHWAY 7 HOT SPRINGS VILLAGE AR 71909
1303483 JACKS PHARMACY INC 103 E COLLEGE AVE ST MARIES ID 83861-2297
2371273 WALGREENS #11954 802 E CLOVERLAND DR IRONWOOD MI 49938-1502
2419693 WALMART PHARMACY 10-1654 7295 GLORY ROAD BAXTER MN 56425
2419946 CUB PHARMACY 15350 CEDAR AVE APPLE VALLEY MN 55124
2424884 FAIRVIEW UNIVERSITY DISCHARGE PHAR 500 HARVARD STREET SOUTHEAST MINNEAPOLIS MN 55455
2425177 CUB PHARMACY 1729 MARKET BOULEVARD HASTINGS MN 55033-1254
1035206 WALGREENS 400 COLONY BLVD THE VILLAGES FL 32162-6086
2419542 FAIRVIEW RIDGEVIEW PHARMACY 303 EAST NICOLLET BOULEVARD BURNSVILLE MN 55337
2433314 THRIFTY WHITE PHARMACY #787 246 ELM ST W ANNANDALE MN 55302-1123
4902943 VALLEY DRUG CO 102 E MAIN AVE CHEWELAH WA 99109
0323561 WALGREENS #4791 14285 W GRAND AVE SURPRISE AZ 85374-4297
2415594 WALGREENS #9511 7845 PORTLAND AVE S BLOOMINGTON MN 55420
2422929 CUB PHARMACY 216 7TH ST W MONTICELLO MN 55362
2428717 CVS PHARMACY 2001 NICOLLET AVENUE MINNEAPOLIS MN 55404
2433679 HEALTHEAST PHARMACY - MAPLEWOOD 2945 HAZELWOOD STREET MAPLEWOOD MN 55109
5619068 CVS PHARMACY 42155 WASHINGTON PALM DESERT CA 92211
1068748 WALGREENS #4165 28100 S TAMIAMI TRAIL BONITA SPRINGS FL 34134
1466033 CAREMARK ILLINOIS SPECIALTY PHARMAC800 BIERMANN CT MT PROSPECT IL 60056
2413259 FAIRVIEW LAKES PHARMACY RUSH CITY 780 WEST 4TH STREET RUSH CITY MN 55069
2422537 GOODRICH PHARMACY ANDOVER 15245 BLUE BIRD ST NW ANDOVER MN 55304
2423957 WALMART PHARMACY 10-3209 18185 ZANE STREET ELK RIVER MN 55330
2428200 CVS PHARMACY 4050 DEAN LAKE BLVD SHAKOPEE MN 55379
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
9 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2431562 WALMART PHARMACY 10-5992 20710 KEOKUK AVE LAKEVILLE MN 55044-6620
1067431 WALGREENS #2761 10551 GULF BLVD TREASURE ISLAND FL 33706
2425886 FAIRVIEW COMPOUNDING PHARMACY 711C KASOTA AVE SE MINNEAPOLIS MN 55414
2427880 LUNDS & BYERLYS PHARMACY #51010 55 UNIVERSITY AVE SE MINNEAPOLIS MN 55414
2424466 COSTCO PHARMACY 12547 RIVERDALE BLVD COON RAPIDS MN 55433
2432487 CUB PHARMACY 1540 NEW BRIGHTON BLVD MINNEAPOLIS MN 55413
3404869 WALMART PHARMACY 10-3305 6711 NC HIGHWAY 135 MAYODAN NC 27027
4533635 WALGREENS #9075 701 E NOLANA ST MCALLEN TX 78504
2411091 FAIRVIEW UNIVERSITY CLINIC PHARMACY909 FULTON ST SE 1ST FLOOR MINNEAPOLIS MN 55414-4800
2426179 CVS PHARMACY 2017 COON RAPIDS BLVD COON RAPIDS MN 55433
2429492 WALGREENS #11956 17 DIVISION ST WAITE PARK MN 56387-1349
2623456 WALMART PHARMACY 10-0080 3001 W BROADWAY COLUMBIA MO 65203
5120667 WALMART PHARMACY 10-1672 2500 EAST LAKE SHORE DRIVE ASHLAND WI 54806
0318851 WALMART PHARMACY 10-1646 6131 EAST SOUTHERN AVE. MESA AZ 85206
2622199 WALMART PHARMACY 100871 101 W HIGHWAY 60 MOUNTAINVIEW MO 65548
2400670 CVS PHARMACY # 5537 W BROADWAY AVE CRYSTAL MN 55428
2420456 WALMART PHARMACY 10-1864 8000 LAKELAND AVENUE BROOKLYN PARK MN 55445
2421458 SEIP DRUG 519 DOUGLAS AVE HENNING MN 56551
0305359 WALGREENS #10879 7111 E GOLF LINKS RD TUCSON AZ 85730-1113
2428957 FAIRVIEW NEW BRIGHTON PHARMACY 1151 SILVER LAKE RD NEW BRIGHTON MN 55112
1483546 EXTENDED PHARMACY LLC 121 STATE ST STE 1A PEORIA IL 61602-1547
1616854 HY-VEE PHARMACY #6 (1063) 4035 MT VERNON ROAD CEDAR RAPIDS IA 52403
2404250 FRANKS PHARMACY INC 1 VERMILION DR COOK MN 55723
3439824 WALGREENS 1706 N SANDHILLS BLVD ABERDEEN NC 28315
5115868 MOST PHARMACY 201 N BROAD ST PRESCOTT WI 54021-1703
2427094 CVS PHARMACY 2426 W BROADWAY AVE MINNEAPOLIS MN 55411
2427347 WALGREENS #1002 3255 VICKSBURG LN N PLYMOUTH MN 55447
2429101 WALGREENS 4205 EGAN RD SAVAGE MN 55378
2432413 RAINBOW PHARMACY 140 W 66TH STREET RICHFIELD MN 55423
1042427 WALGREENS #4217 4029 S SUNCOAST BLVD HOMOSASSA FL 34446
4576041 WALMART PHARMACY 10-0470 1821 S PADRE ISLAND DR CORPUS CHRISTI TX 78416-1352
5116062 FAMILY FRESH MARKET PHARMACY 303 SOUTH MAIN ST RIVER FALLS WI 54022
0358918 CVS PHARMACY #05530 15300 N. COTTON LANE SURPRISE AZ 85388-9613
2428096 WALMART PHARMACY 10-4244 1303 CHARLES STREET PARK RAPIDS MN 56470
2433338 CUB PHARMACY 1592 10881 UNIVERSITY AVE NE BLAINE MN 55434-8032
4351742 WALMART PHARMACY 10-3237 5521 E ARROWHEAD PARKWAY SIOUX FALLS SD 57110
0319120 WALMART PHARMACY 10-1746 1380 WEST ELLIOTT ROAD TEMPE AZ 85284-1102
2415188 THRIFTY WHITE PHARMACY #727 223 STATE ST N WASECA MN 56093-2927
2427614 WALGREENS #9794 7940 PENN AVE S BLOOMINGTON MN 55431-1315
2428490 CVS PHARMACY 15115 DOVE TRAIL APPLE VALLEY MN 55124
2429024 EAST SIDE FAMILY CLINIC PHARMACY 895 E 7TH ST ST PAUL MN 55106
0227339 FRED MEYER PHARMACY #649 535 W EVERGREEN AVE PALMER AK 99645
2419883 CVS PHARMACY # 4175 VINEWOOD LN N PLYMOUTH MN 55442
2429187 THRIFTY WHITE PHARMACY #771 4570 COUNTY HIGHWAY 61 MOOSE LAKE MN 55767
2431904 GUIDEPOINT PHARMACY #109 1472 COUNTY ROAD 5 LONGVILLE MN 56655-3002
4533039 WALGREENS #7537 3777 GATTIS SCHOOL RD ROUND ROCK TX 78664
4592552 HEB PHARMACY 2950 SOUTHMOST RD BROWNSVILLE TX 78521
0322610 WALGREENS #4188 55 W APACHE TRAIL APACHE JUNCTION AZ 85120-3412
1490414 WALGREENS #16394 407 E GREEN ST CHAMPAIGN IL 61820-5610
2418487 CUB PHARMACY 1940 CLIFF LAKE RD EAGAN MN 55122
2426042 WALGREENS #1951 612 4TH ST NW FARIBAULT MN 55021
4438316 WALGREENS #9340 2109 WILMA RUDOLPH BLVD CLARKSVILLE TN 37040
4553043 WALGREENS #12837 510 N ALAMO RD ALAMO TX 78516-2306
0132580 WALMART PHARMACY 10-2748 170 FORT MORGAN ROAD GULF SHORES AL 36542
0323802 OMNICARE OF CHANDLER 6825 WEST GALVESTON ST CHANDLER AZ 85226
2406088 HEALTH SERVICES PHARMACY 21 CARKOSKI COMMONS MANKATO MN 56001
2431156 CVS PHARMACY # 6540 PENN AVE S RICHFIELD MN 55423-1143
3432224 WALMART PHARMACY 10-2440 210 WAL-MART PLAZA SYLVA NC 28779
5132181 PHILLIPS TOTAL CARE PHARMACY, INC. 121 E STATE ST MAUSTON WI 53948-1344
3813424 HI-SCHOOL PHARMACY #1187 110 SW HWY101 WALDPORT OR 97394
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
10 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
4551506 WALMART PHARMACY 10-4508 1705 EXPRESSWAY 83 PENITAS TX 78576
2419390 WALGREENS #5882 4200 WINNETKA AVE NEW HOPE MN 55428
2432223 FAIRVIEW PHARMACY ROSEMOUNT 15075 CIMARRON AVE STE 3 ROSEMOUNT MN 55068-1635
5120415 WALGREENS 1819 S HASTINGS WAY EAU CLAIRE WI 54701-4504
5135149 VILLAGE PHARMACY AT WWH 1100 BERGSLIEN ST BALDWIN WI 54002-0015
0317328 SAFEWAY PHARMACY #0216 1650 MCCULLOCH BLVD LAKE HAVASU AZ 86403
0325882 WALGREENS #6440 6951 S KINGS RANCH RD GOLD CANYON AZ 85118-3012
1080439 CVS PHARMACY 1300 SW ST LUCIE BLVD PORT SAINT LUCIE FL 34986
1082229 CVS PHARMACY 4562 HWY 20 E NICEVILLE FL 32578
1091482 WALGREENS #5068 10 S CONGRESS AVE DELRAY BEACH FL 33445
2423666 HY-VEE PHARMACY (1400) 900 E MAIN ST MARSHALL MN 56258
2430875 MAYO CLINIC PHARMACY SUBWAY 200 FIRST STREET SW ROCHESTER MN 55905
2432247 THRIFTY WHITE PHARMACY #782 45 LADY LUCK DRIVE HINCKLEY MN 55037
3211947 WALGREENS #12270 2101 NORTHERN BLVD NE RIO RANCHO NM 87124-4727
5101085 RIPON DRUG 328 WATSON ST RIPON WI 54971-1517
5109930 JAMES PHARMACY LTD 215 MAPLE STREET TURTLE LAKE WI 54889
1133088 KROGER PHARMACY 3455 PEACHTREE IND BLVD DULUTH GA 30096
0318700 WALMART PHARMACY 10-1598 4617 EAST BELL ROAD PHOENIX AZ 85032
2400101 WALGREENS #7290 1270 E MADISON AVE MANKATO MN 56001
2415253 PARK NICOLLET PHARMACY EAGAN 1885 PLAZA DRIVE EAGAN MN 55122
2416990 NORTH SHORE PHARMACY 21 WEST HIGHWAY 61 GRAND MARAIS MN 55604
2422234 CENTRACARE PHARMACY BECKER 12800 ROLLING RIDGE RD BECKER MN 55308
2423870 SAMS PHARMACY 10-6318 3745 LOUISIANA AVE SOUTH ST. LOUIS PARK MN 55426
2427703 WALGREENS #10289 18267 CARSON CT ELK RIVER MN 55330
2433592 HEALTHEAST PHARMACY - ST. PAUL 17 W EXCHANGE ST ST PAUL MN 55102
1149269 WALGREENS #6481 3584 WESLEY CHAPEL RD DECATUR GA 30034
1203518 FOODLAND PHARMACY #24 55 PUKALANI ST PUKALANI HI 96768
2419667 WALGREENS #5883 6800 BASS LAKE RD CRYSTAL MN 55428
2425002 MAYO CLINIC PHARMACY EISENBERG 201 CENTER ST W ROCHESTER MN 55902
2432639 FAIRVIEW PHARMACY BURNSVILLE SCC 14101 FAIRVIEW DR STE 100 BURNSVILLE MN 55337-2507
3458189 PINEHURST MEDICAL CLINIC PHARMACY 15 REGIONAL DR PINEHURST NC 28374
4435447 FRESENIUS MEDICAL CARE RX 1000 CORPORATE CENTRE DR FRANKLIN TN 37067-2011
5103180 SPRING VALLEY DRUG 104 S MCKAY AVE SPRING VALLEY WI 54767
5708447 WALGREENS 391 S TAMIAMI TRL VENICE FL 34285-2423
0314586 WALGREENS #5776 1451 N DYSART RD AVONDALE AZ 85323
0315324 WALGREENS #4435 4420 E BROWN MESA AZ 85205
0353413 WALGREENS #9652 1575 N ARIZONA BLVD COOLIDGE AZ 85128-3215
0353881 CVS PHARMACY 19602 R H JOHNSON SUN CITY WEST AZ 85375
1620803 WALGREENS #5852 3030 UNIVERSITY DES MOINES IA 50311
2407408 NUCARA PHARMACY #23 216 WASHBURNE AVE PAYNESVILLE MN 56362
2423301 CUB PHARMACY 1750 W COUNTY RD 42 BURNSVILLE MN 55337
2424430 CVS PHARMACY # 4848 COUNTY ROAD 101 MINNETONKA MN 55345
2426054 THRIFTY WHITE DRUG #754 441 NORTH ARROWHEAD LANE MOOSE LAKE MN 55767
2430382 COBORN'S PHARMACY #2042 1010 ENTERPRISE DR E BELLE PLAINE MN 56011-2340
2430659 CVS PHARMACY # 06649 4656 EXCELSIOR BLVD. SAINT LOUIS PARK MN 55416-4938
2635071 WALGREENS 2620 S BELT HWY ST JOSEPH MO 64503
4610259 WALGREENS #9238 531 E 400 S SALT LAKE CITY UT 84102
5133107 UNITY PHARMACY 1504 190TH AVE BALSAM LAKE WI 54810-7102
5900990 MEDTRONIC PHARMACY 18302 TALAVERA RDG SAN ANTONIO TX 78257-2605
0319269 WALGREENS #5890 11250 E VIA LINDA SCOTTSDALE AZ 85259
0322292 SAFEWAY PHARMACY #1536 401 E HWY 260 PAYSON AZ 85541
0353855 CVS PHARMACY 2350 MIRACLE MILE BULLHEAD CITY AZ 86442
1091711 WALGREENS #5757 3909 HWY 90 PACE FL 32571
2409438 BLOOMINGTON DRUG 509 W 98TH ST BLOOMINGTON MN 55420-4713
2412637 PARK NICOLLET PHARMACY BURNSVILLE 14000 FAIRVIEW DRIVE BURNSVILLE MN 55337
2424428 CVS PHARMACY # 111 PIONEER TRL CHASKA MN 55318
2424606 SAMS PHARMACY 10-6254 16701 94TH AVENUE NORTH MAPLE GROVE MN 55311
2432401 CUB PHARMACY 1104 LAGOON AVENUE MINNEAPOLIS MN 55408
0319067 WALGREENS #2555 178 E SHELDON PRESCOTT AZ 86301
0356370 CVS PHARMACY #09309 4744 S HIGHWAY 95 FORT MOHAVE AZ 86426-9377
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
11 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
1077355 CVS PHARMACY 105 S PEBBLE BEACH BLVD SUN CITY CENTER FL 33573
2412435 FAMILY FRESH MARKET PHARMACY 3326 115 ELM STREET FARMINGTON MN 55024
2424187 WALGREENS #5080 10180 HENNEPIN TOWN RD EDEN PRAIRIE MN 55347
2424719 HY-VEE PHARMACY (1896) 1475 SERVICE ROAD WINONA MN 55987
2429632 WALGREENS #12592 326 W LINCOLN AVE FERGUS FALLS MN 56537
5648552 WALGREENS 301 UNIVERSITY AVE SAN DIEGO CA 92103-3008
1036753 WALGREENS #1004 1625 TAYLOR RD PORT ORANGE FL 32128-7537
1600293 WALGREENS 2508 W BROADWAY COUNCIL BLUFFS IA 51501
2371196 WALGREENS #11953 300 E F STREET IRON MOUNTAIN MI 49801-3442
5700441 CVS PHARMACY 15550 SAN CARLOS BLVD. FT. MYERS FL 33908-2550
0202224 FRED MEYER PHARMACY #653 1501 E PARKS HWY WASILLA AK 99654-8283
0323511 WALGREENS #4620 15490 W BELL RD SURPRISE AZ 85374-3496
1000203 WALGREENS 2355 NORTHEAST 26TH ST FT LAUDERDALE FL 33305-1628
1068609 CVS PHARMACY # 6150 14TH ST W BRADENTON FL 34207
2412803 ST THERESE PHARMACY 8000 BASS LAKE RD NEW HOPE MN 55428-3199
2422676 COBORNS PHARMACY #2019 1100 7TH AVE SOUTH PRINCETON MN 55371
2424997 MAYO CLINIC PHARMACY MARY BRIGH 1216 2ND ST SW ROCHESTER MN 55902
2431079 WALGREENS 1004 HIGHWAY 25 N BUFFALO MN 55313-1920
5131103 WALGREENS #11860 502 S MAIN ST RICE LAKE WI 54868-2576
0318813 WALMART PHARMACY 10-1381 2555 W APACHE TRL APACHE JUNCTION AZ 85120-5204
0321872 WALGREENS #03728 7059 E BASELINE RD MESA AZ 85209-4803
0326769 WALGREENS #6411 11951 N 1ST AVE ORO VALLEY AZ 85737
1095997 WALGREENS #6775 15295 COLLIER BLVD NAPLES FL 34119
2415669 LAKES AREA PHARMACY INC 30503 PATRIOT AVE PEQUOT LAKES MN 56472
2421078 CUB PHARMACY 615 W CENTRAL ENTRANCE DULUTH MN 55811
2800046 WALGREENS #03182 7045 O STREET LINCOLN NE 68510-2426
2816532 WALMART PHARMACY 10-3278 8700 ANDERMATT DRIVE LINCOLN NE 68526
4600917 SMITHS PHARMACY #94 455 SOUTH 500 EAST SALT LAKE CITY UT 84102
5631040 CVS PHARMACY 42150 JACKSON ST INDIO CA 92203
0327115 CVS PHARMACY 2809 S SOSSAMAN RD MESA AZ 85212
0421280 WALGREENS #5535 4634 N HWY 7 HOT SPRINGS VILLAGE AR 71909
1006356 WALGREENS 10697 ULMERTON RD LARGO FL 33771
2423250 CUB PHARMACY 246 57TH AVE NE FRIDLEY MN 55432-5420
2428642 FAIRVIEW ANDOVER PHARMACY 13819 HANSON BLVD ANDOVER MN 55304
2430510 CVS PHARMACY # 1610 MONKS AVE MANKATO MN 56001-5173
3502475 UNIVERSITY OF NORTH DAKOTA 2891 2ND AVE N STOP 9038 GRAND FORKS ND 58202-9038
5129110 CVS PHARMACY 2135 SILVERNAIL RD PEWAUKEE WI 53072
5901562 GIBSON PHARMACY 815 N OCONNOR RD IRVING TX 75061
0322470 WALGREENS #4103 10405 LA CANADA DRIVE ORO VALLEY AZ 85737
0328030 WALMART PHARMACY 10-5257 5122 EAST UNIVERSITY DRIVE MESA AZ 85205
0357283 BRISMA PHARMACY 590 N ALMA SCHOOL RD CHANDLER AZ 85224-4361
0609959 WALGREENS #5645 205 E EISENHOWER BLVD LOVELAND CO 80537
2429175 WALGREENS 3605 ROUND LAKE BLVD. NW ANOKA MN 55303
2429707 CHILDREN'S HOSPTIALS AND CLINICS OF 2530 CHICAGO AVE SOUTH MINNEAPOLIS MN 55404-4570
3127811 WALGREENS #03146 561-579 IRVINGTON AVE NEWARK NJ 07106
3724689 WESTMINSTER FAMILY DRUG 10911 NE 23RD NICOMA PARK OK 73066
5134414 CVS PHARMACY #10411 433 BROADWAY ST S MENOMONIE WI 54751-1822
0137061 WALMART PHARMACY 10-5653 25241 PERDIDO BEACH BLVD ORANGE BEACH AL 36561
0317140 WALGREENS #2232 313 W ESPERANZA GREEN VALLEY AZ 85614
1023655 WALMART PHARMACY 10-4262 4085 WEDGEWOOD LANE THE VILLAGES FL 32162
1064841 CVS PHARMACY 1920 A1A SOUTH SAINT AUGUSTINE FL 32080
1625144 CVS PHARMACY # 2420 LINCOLN WAY STE 104 AMES IA 50014-7217
2404426 OTT DRUG STORE 117 MAIN AVE E DEER RIVER MN 56636-0577
2418374 WALGREENS #2038 3240 W LAKE ST MINNEAPOLIS MN 55416
2419768 CVS PHARMACY # 1850 ADAMS ST MANKATO MN 56001
2429656 WALGREENS #11835 7200 CEDAR LAKE RD ST LOUIS PARK MN 55426-2725
3504291 CVS PHARMACY 1950 32ND AVE S GRAND FORKS ND 58201
5134161 GENOA, A QOL HEALTHCARE COMPANY, LL1707 MAIN ST STE 102 LA CROSSE WI 54601-4200
5707724 PUBLIX PHARMACY #1289 3035 SE MARICAMP RD. OCALA FL 34471
1047441 CVS PHARMACY 6202 US HWY 41 N APOLLO BEACH FL 33572
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
12 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2418831 CUB PHARMACY 2850 26TH AVE S MINNEAPOLIS MN 55406
2424810 WEBER & JUDD NURSING CARE RX 1814 15TH ST NW ROCHESTER MN 55901-0214
2428755 CVS PHARMACY 17665 KENWOOD TRAIL LAKEVILLE MN 55044
2429745 WALMART PHARMACY 10-2198 700 AMERICAN BLVD E BLOOMINGTON MN 55420
2432653 COMO PHARMACY 217 COMO AVE STE 107 SAINT PAUL MN 55103-1838
2432956 HY-VEE PHARMACY #4 (1556) 4221 W CIRCLE DRIVE NW ROCHESTER MN 55901-8788
5126746 WALMART PHARMACY 10-3245 15594 STATE HIGHWAY 77 HAYWARD WI 54843
1058026 WALMART PHARMACY 10-1029 6885 S SUNCOAST BLVD HOMOSASSA SPRINGS FL 34446
1063421 WALMART PHARMACY 10-1362 15017 EMERALD COAST PKWY DESTIN FL 32541
1093943 WALGREENS #6135 8315 MARKET ST BRADENTON FL 34202
2400682 CVS PHARMACY # 1902 MILLER TRUNK HWY DULUTH MN 55811
2408323 CAPITOL PHARMACY INC 580 RICE ST ST PAUL MN 55103
2416685 COBORNS PHARMACY #2023 19425 EVANS ST SW ELK RIVER MN 55330
2422082 CUB PHARMACY 6775 YORK AVE S EDINA MN 55435
2424632 GOODRICH PHARMACY ST FRANCIS 23122 ST FRANCIS BLVD ST FRANCIS MN 55070
2425812 LUNDS & BYERLYS PHARMACY #1007 3777 PARK CENTER BLVD ST LOUIS PARK MN 55416
2428678 WALGREENS #11157 910 BROADWAY ST ALEXANDRIA MN 56308-1814
2433439 HY-VEE PHARMACY (1559) 6150 EGAN DRIVE SAVAGE MN 55378-2699
2433465 CENTER DRUG PHARMACY 111 HUNDERTMARK RD STE 100 CHASKA MN 55318-1110
4594330 WALMART PHARMACY 10-0508 1216 JUNCTION HWY KERRVILLE TX 78028
4847072 HARRIS TEETER PHARMACY #308 2675 AVENIR PL VIENNA VA 22180-7176
5126835 WALGREENS #6935 10 PARK RIDGE DRIVE STEVENS POINT WI 54481
5129158 CVS PHARMACY 2607 N DOWNER AVE MILWAUKEE WI 53211
5622003 WALGREENS 1700 E VISTA CHINO PALM SPRINGS CA 92262-3511
0318205 FRYS FOOD AND DRUG 500 W 24TH STREET YUMA AZ 85364
0354100 CVS PHARMACY 19505 N SUNRISE BLVD SURPRISE AZ 85374
0619746 KING SOOPERS PHARMACY 25637 CONIFER ROAD CONIFER CO 80433
1002562 WALGREENS #74 1634 SOUTH FEDERAL BOYNTON BEACH FL 33435
1026853 WALGREENS #9298 21950 S TAMIAMI TRAIL ESTERO FL 33928
1051250 WALGREENS #4398 1477 MAIN ST DUNEDIN FL 34698
2348046 ALLIANCERX WALGREENS PRIME #15438 41460 HAGGERTY CIRCLE S CANTON MI 48188-2227
2402066 SCHNEIDER DRUG 3400 UNIVERSITY AVE SE MINNEAPOLIS MN 55414
2415239 HEALTHPARTNERS CENTRAL MN CLINIC PH2251 CONNECTICUT AVENUE S SARTELL MN 56377-4772
2421890 NORTH MEMORIAL HEALTH PHARMACY - R3300 OAKDALE AVE N ROBBINSDALE MN 55422
2427373 CVS PHARMACY 5801 BROOKLYN BLVD BROOKLYN CENTER MN 55429
2427727 COSTCO PHARMACY 11330 FOUNTAINS DR N MAPLE GROVE MN 55369
2430217 CVS PHARMACY 316 15TH AVE SE MINNEAPOLIS MN 55415
2430394 NORTH MEMORIAL HEALTH PHARMACY - M9825 HOSPITAL DR MAPLE GROVE MN 55369-4479
2431752 WALGREENS 215 DODDRIDGE AVE CLOQUET MN 55720-2372
2433415 HEALTHPARTNERS PHARMACY #87017 9700 W 76TH ST STE 106 EDEN PRAIRIE MN 55344-4200
3404504 UNC HOSPITALS CENTRAL OUTPATIENT PH101 MANNING DR CHAPEL HILL NC 27514
4542266 WALGREENS #10449 7163 S PADRE ISLAND DR CORPUS CHRISTI TX 78412-4913
5109500 RED CROSS PHARMACY 146 WALNUT ST SPOONER WI 54801-1319
5709259 FAMILY CARE RX, LLC 4752 S JOG RD GREENACRES FL 33467-5119
0130358 WALGREENS #6084 2 SOUTH GREENO RD FAIRHOPE AL 36532
0305347 WALGREENS #813 15442 99TH AVE SUN CITY AZ 85351
1049091 WALGREENS #13630 1301 2ND AVE SW LARGO FL 33770-3120
1080960 WALGREENS #4282 1504 53RD AVE E BRADENTON FL 34203
2417752 PERHAM HEALTH PHARMACY 1000 CONEY STREET WEST PERHAM MN 56573
2421066 COBORNS PHARMACY #2001 110 FIRST ST S SAUK RAPIDS MN 56379
2425785 WALGREENS #7812 21495 141ST AVE N ROGERS MN 55374
2426890 PARK NICOLLET PHARMACY CHANHASSEN 300 LAKE DRIVE EAST CHANHASSEN MN 55317
2427169 WALGREENS 421 PAUL BUNYAN DR NW BEMIDJI MN 56601
2427676 CVS PHARMACY # 300 CLYDESDALE TRL MEDINA MN 55340
2429733 PARK NICOLLET PHARMACY MAPLE GROVE9555 UPLAND LN N MAPLE GROVE MN 55369
2431966 CVS PHARMACY #10397 25 SECOND ST NE AITKIN MN 56431
2432552 PARK NICOLLET PHARMACY TRIA 8100 NORTHLAND DR BLOOMINGTON MN 55431-4800
2432906 HY-VEE PHARMACY (1439) 8200 42ND AVE N NEW HOPE MN 55427-1100
2433681 COSTCO PHARMACY#1272 7070 TAMARACK RD WOODBURY MN 55125-1205
4833148 CVS PHARMACY # 4630 MONTICELLO AVE WILLIAMSBURG VA 23188
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
13 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
4925662 WALGREENS #03723 7451 CIRQUE DR W UNIVERSITY PLACE WA 98466
5120706 SCHMITZS ECONOMART 700 S RIVER ST SPOONER WI 54801
5130795 WALGREENS 311 E CAMPUS MALL MADISON WI 53715
5628168 WALGREENS 78218 VARNER RD PALM DESERT CA 92211-4134
5800885 CVS PHARMACY 16 NEW SCOTLAND AVENUE ALBANY NY 12208-3555
0130459 WINN DIXIE 1550 GOVERNMENT ST MOBILE AL 36604
0321795 ARIZONA HOME CARE 1626 S EDWARD DR TEMPE AZ 85281
0354580 WALMART PHARMACY 3833 1606 SOUTH SIGNAL BUTTE ROAD MESA AZ 85209-1482
0356483 WALGREENS #12334 1654 N PEBBLE CREEK PKWY. GOODYEAR AZ 85395
1034759 WALGREENS 10672 COLONIAL BLVD FORT MYERS FL 33913
1466653 PHARMACY SOLUTIONS 1 NORTH WAUKEGAN ROAD NORTH CHICAGO IL 60064-6335
1715830 CAREMARK KANSAS SPECIALTY PHARMAC 11162 RENNER BLVD LENEXA KS 66219-9621
2420658 WALMART PHARMACY 10-1473 1881 MADISON AVENUE MANKATO MN 56001
2423440 CVS PHARMACY # 1370 HIGHWAY 15 S HUTCHINSON MN 55350
2425545 COBORNS PHARMACY #2031 711 ROSE DR BIG LAKE MN 55309
2427032 LUNDS & BYERLYS PHARMACY #51006 5159 W 98TH ST BLOOMINGTON MN 55437
2431144 CVS PHARMACY # 329 FRAZEE ST E DETROIT LAKES MN 56501-3603
3003439 CVS PHARMACY 268 WEST ST KEENE NH 03431
4551075 CVS PHARMACY 1500 PADRE BLVD SOUTH PADRE ISLAND TX 78597-6726
5621037 CVS PHARMACY 8831 VILLA LA JOLLA LA JOLLA CA 92037
0328129 CVS PHARMACY # 9615 E OLD SPANISH TRL TUCSON AZ 85748
0591722 COSTCO PHARMACY 2400 MONUMENT BLVD CONCORD CA 94518
1028491 CVS PHARMACY # 1890 NE PINE ISLAND ROAD CAPE CORAL FL 33909
1095911 CVS PHARMACY # 2430 SANTA BARBARA BLVD CAPE CORAL FL 33914
1117096 CVS PHARMACY 960 N COLUMBIA ST MILLEDGEVILLE GA 31061
2419314 CUB PHARMACY 12900 RIVERDALE DR COON RAPIDS MN 55448
2428325 FARIVIEW PHARMACY MAPLE GROVE 14500 99TH AVE N MAPLE GROVE MN 55369
2429973 THRIFTY WHITE PHARMACY #776 400 MAIN ST COLD SPRING MN 56320
2430988 CVS PHARMACY # 6905 YORK AVE, S. EDINA MN 55435
2431106 UNITED HOSPITAL PHARMACY 333 SMITH AVE N SAINT PAUL MN 55102-2344
2431601 GENOA, A QOL HEALTHCARE COMPANY, LL1811 WEIR DR STE 275 WOODBURY MN 55125-2201
2432386 CUB PHARMACY 5370 16TH AVE ST LOUIS PARK MN 55416
2433340 HEALTHPARTNERS PHARMACY #86017 9700 W 76TH ST DOOR 106 EDEN PRAIRIE MN 55344-4201
2633611 EXPRESS SCRIPTS SPECIALTY DIST SVCS 8931 SPRINGDALE AVE STE A SAINT LOUIS MO 63134-2400
5128043 WALGREENS #9214 2626 ROSE ST LA CROSSE WI 54603
5903768 WALGREENS #13931 100 E EXPRESSWAY 83 MISSION TX 78572-6008
0315540 WALGREENS #03913 2360 S HIGHWAY 95 BULLHEAD CITY AZ 86442-7303
0325060 FRYS FOOD AND DRUG 5100 S MCCLINTOCK DR TEMPE AZ 85282
0325983 WALGREENS #5701 1158 S CRISMON MESA AZ 85208
0356837 WALMART PHARMACY 10-4252 2601 E HUNTINGTON DR FLAGSTAFF AZ 86004
1045966 WALMART PHARMACY 10-0528 2911 53RD AVENUE EAST BRADENTON FL 34203
1065336 WALMART PHARMACY 10-1536 10237 BAY PINES BLVD ST PETERSBURG FL 33708-3131
1071543 CVS PHARMACY 1612 E SILVER STAR RD OCOEE FL 34761
1087332 WALGREENS #5340 9998 FRONT BEACH RD PANAMA CITY BEACH FL 32407
1483356 CVS PHARMACY # 08980 6510 N SHERIDAN RD CHICAGO IL 60626-5312
1619622 CVS PHARMACY # 320 S DUFF AVE AMES IA 50010
2400187 WALGREENS 2505 W DIVISION ST ST CLOUD MN 56301-3837
2413487 METHODIST HOSPITAL PHARMACY 6500 EXCELSIOR BLVD ST LOUIS PARK MN 55426-4700
2416899 THRIFTY WHITE DRUG #736 201 HORACE AVENUE NORTH THIEF RIVER FALLS MN 56701
2421357 CVS PHARMACY # 125 LINCOLN AVE SE SAINT CLOUD MN 56304
2424822 FAIRVIEW OXBORO PHARMACY 600 W 98TH STREET BLOOMINGTON MN 55420
2424911 WESTSIDE COMMUNITY HEALTH SERVICES 153 CESAR CHAVEZ ST ST PAUL MN 55107
2426915 CVS PHARMACY 7901 BASS LAKE RD NEW HOPE MN 55428
2426927 CUB PHARMACY 8600 114TH AVE N CHAMPLIN MN 55316
2427943 THRIFTY WHITE PHARMACY #767 127 2ND AVE SW MILACA MN 56353
2818702 HY-VEE PHARMACY (1323) 5212 3RD AVENUE KEARNEY NE 68845-2831
4928668 BARTELL DRUGS #54 3601 6TH AVENUE SOUTH TACOMA WA 98406-5405
0352409 BASHAS 142 E HIGHWAY 260 PAYSON AZ 85541
1042035 WALGREENS 2710 DEL PRADO BLVD SOUTH CAPE CORAL FL 33904-5788
1152088 PUBLIX PHARMACY #1089 5180 MCGINNIS FERRY ROAD ALPHARETTA GA 30005
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
14 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
1719193 CVS PHARMACY 2300 IOWA ST LAWRENCE KS 66046
2408056 LONGBELLA DRUG INC 421 2ND AVE NE STAPLES MN 56479-2539
2416394 CVS PHARMACY # 8225 FLYING CLOUD DR EDEN PRAIRIE MN 55344
2417651 WALGREENS #1916 13611 GROVE DR MAPLE GROVE MN 55311
2422361 CVS PHARMACY # 860 MANKATO AVE WINONA MN 55987
2424074 STERLING LTC PHARMACY 1601 STATE AVE NW OWATONNA MN 55060
2427602 CUB PHARMACY 9655 COLORADO LN N BROOKLYN PARK MN 55445
2429834 WALGREENS #11834 80 14TH ST SW ROCHESTER MN 55902-3821
2430774 FAMILY FARE PHARMACY 3348 425 MAIN ST W CANNON FALLS MN 55009-2095
2430902 GENOA, A QOL HEALTHCARE COMPANY, LL3101 OLD HIGHWAY 8 STE 203B ROSEVILLE MN 55113-1072
2432336 FAIRVIEW PHARMACY FRIDLEY 6341 UNIVERSITY AVE NE STE 101 FRIDLEY MN 55432-4946
2433287 HY-VEE PHARMACY (1165) 1500 CENTRAL PARK COMMONS DR EAGAN MN 55121-8702
3196563 DIGINO'S APOTHECARY 255 VALLEY BLVD WOOD RIDGE NJ 07075-1201
3724627 WALMART PHARMACY 10-3430 9011 NE 23RD STREET MIDWEST CITY OK 73141
4230378 PUBLIX PHARMACY #1266 1724 STATE RD. SUMMERVILLE SC 29483
0132592 WALGREENS #1230 1421 GULF SHORES PKWY GULF SHORES AL 36542
0315463 WALGREENS #6533 100 S BEELINE HWY PAYSON AZ 85541
0327242 CVS PHARMACY 9901B W THUNDERBIRD BLVD SUN CITY AZ 85351
0618960 CVS PHARMACY # 2800 PEARL ST BOULDER CO 80301
1003805 WALGREENS #15192 710 150TH AVE MADEIRA BEACH FL 33708
1054333 WALGREENS #12698 3001 TAMIAMI TRL PORT CHARLOTTE FL 33952-6601
1070678 CVS PHARMACY # 13711 S TAMIAMI TRL FORT MYERS FL 33912
1076252 CVS PHARMACY # 250 E MIRACLE STRIP PKWY MARY ESTHER FL 32569
1078814 WALGREENS #3988 10563 PARK BLVD SEMINOLE FL 33772
1084728 WALGREENS #4645 1534 CAPE CORAL PKWY W CAPE CORAL FL 33914
1086683 CVS PHARMACY 12255 S CLEVELAND AVE FORT MYERS FL 33907
1706982 WATKINS HEALTH CENTER PHARMACY 1200 SCHWEGLER DR LAWRENCE KS 66045-7538
2408195 ST. CLOUD VAMC PHARMACY 4801 VETERANS DR ST CLOUD MN 56303-2015
2419744 CVS PHARMACY # 14546 DELLWOOD DR BAXTER MN 56425
2421054 CUB PHARMACY 8150 WEDGEASTWOOD LN MAPLE GROVE MN 55369
2423589 WALMART PHARMACY 10-2812 25 25TH STREET S.E. ROCHESTER MN 55904
2427335 GOODRICH PHARMACY BLAINE 11855 ULYSSES ST NE BLANE MN 55434
2427917 LONGBELLA DRUG CLINIC 49725 COUNTY RD 83 STAPLES MN 56479
2431271 COMMUNITY, A WALGREENS PHARMACY #2100 LYNDALE AV S MINNEAPOLIS MN 55405
3461578 MISSION PARDEE HEALTH CAMPUS PHARM2695 HENDERSONVILLE RD ARDEN NC 28704-8576
5132460 WALGREENS 4415 STATE ROAD 16 LA CROSSE WI 54601-1815
5625958 DIPLOMAT SPECIALTY PHARMACY 15211 VANOWEN STREET VAN NUYS CA 91405-3606
5704146 WALGREENS 9150 KINGS CROSSING RD FORT MYERS FL 33912-0848
5728223 WALMART PHARMACY 10-4063 17105 SAN CARLOS BLVD FORT MYERS BEACH FL 33931-5336
0539316 IONE PHARMACY 307 PRESTON AVE IONE CA 95640
0700890 PETRICONES TORRINGTON PHARMACY 110 E MAIN ST TORRINGTON CT 06790-5492
1620334 HY-VEE MAINSTREET (7070) 2611 PIERCE ST SIOUX CITY IA 51104
2408171 ST. CLOUD STATE UNIVERSITY HEALTH SE251 6TH STREET SOUTH ST CLOUD MN 56301-4498
2421319 ALLINA HEALTH PIPER BUILDING PHARMA 913 E 26TH STREET MINNEAPOLIS MN 55404
2421408 ALLINA HEALTH WESTHEALTH PHARMACY 2855 CAMPUS DR PLYMOUTH MN 55441-2616
2425963 FAIRVIEW CEDAR RIDGE PHARMACY 15650 CEDAR AVENUE SOUTH APPLE VALLEY MN 55124
2430089 FAIRVIEW PHARMACY BLAINE 10961 CLUB WEST PKWY BLAINE MN 55449-5866
2433516 THRIFTY WHITE PHARMACY #788 2410 S POKEGAMA AVE GRAND RAPIDS MN 55744-2503
2640440 CVS PHARMACY# 04403 7470 MANCHESTER RD MAPLEWOOD MO 63143-3032
3302837 DUANE READE 949 3RD AVENUE NEW YORK NY 10022
3361019 WALGREENS #9971 41 HOLLAND AVE. ALBANY NY 12208-3408
3503441 FAMILY MEDICINE RESIDENCY PHARMACY 725 HAMLINE ST GRAND FORKS ND 58203
4225733 KROGER PHARMACY 1795 WHISKEY ROAD AIKEN SC 29803
4591055 ALLIANCERX WALGREENS PRIME #15443 10530 JOHN ELLIOTT DR FRISCO TX 75033
0325945 WALGREENS #5312 375 W CONTINENTAL RD GREEN VALLEY AZ 85622-3552
0353730 CVS PHARMACY 1900 W VALENCIA RD TUCSON AZ 85746
0358653 GENRX 17250 N HARTFORD DR STE 115 SCOTTSDALE AZ 85255-4248
1077456 WALGREENS #3527 567 NE 125TH NORTH MIAMI FL 33161
1307140 HEARTLAND PHARMACY 3250 E 17TH ST AMMON ID 83406
1718824 CVS PHARMACY 6510 NIEMAN RD SHAWNEE KS 66203
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
15 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2416926 SHOPKO PHARMACY 501 HIGHWAY 10 SE SAINT CLOUD MN 56304-1250
2418944 CASH WISE PHARMACY #3004 1300 5TH ST SE WILLMAR MN 56201
2419655 PARK NICOLLET PHARMACY BROOKDALE 6000 EARLE BROWN DRIVE BROOKLYN CENTER MN 55430
2426600 FAIRVIEW EDEN PRAIRIE PHARMACY 830 PRAIRIE CENTER DRIVE EDEN PRAIRIE MN 55344
2427222 WALGREENS #9728 600 79TH ST W CHANHASSEN MN 55317
2427361 CVS PHARMACY 10930 UNIVERSITY AVE NW COON RAPIDS MN 55448-6120
2428111 WALGREENS #10501 5474 MOUTAIN IRON DR VIRGINIA MN 55792-3371
2433643 GENOA, A QOL HEALTHCARE COMPANY, LL149 THOMPSON AVE E STE 150 SAINT PAUL MN 55118-3238
2635627 WALMART PHARMACY 10-5150 1900 MAPLEWOOD COMMONS DRIVE MAPLEWOOD MO 63143
2800058 WALGREENS #05143 7151 CASS ST OMAHA NE 68132
3410901 WALGREENS 2501 HENDERSONVILLE RD ARDEN NC 28704-9576
3427348 WALMART PHARMACY 10-1558 304 E ARBOR LANE EDEN NC 27288
3500736 NDSU STUDENT HEALTH SERVICE PHARMA1707 CENTENNIAL BLVD FARGO ND 58102
5114195 WALGREENS #10496 192 N MAIN ST FOND DU LAC WI 54935-3462
5115034 WALGREENS 900 WEST AVE S LA CROSSE WI 54601-4729
5125693 WALGREENS 1995 MAIN STREET GREEN BAY WI 54302
5636660 WALGREENS 4420 MISSOURI FLAT RD PLACERVILLE CA 95667-6813
5910941 CVS PHARMACY # 710 HIGHWAY 361 PORT ARANSAS TX 78373
0202565 SAMS PHARMACY 10-6603 48 COLLEGE ROAD FAIRBANKS AK 99701
0320945 COSTCO PHARMACY 1444 S SOSSAMAN RD MESA AZ 85209-3400
0540066 WALGREENS 44840 MONTEREY AVE PALM DESERT CA 92260
0580591 WALGREENS 423 N SANTA CRUZ AVE LOS GATOS CA 95030
0589296 HENDRICKS PHARMACY 137 N HARVARD AVE CLAREMONT CA 91711
1000087 CVS PHARMACY 110 HWY 98 PORT SAINT JOE FL 32456
1035725 CVS PHARMACY # 9350 DYNASTY DR FT MYERS FL 33905
1052694 WALGREENS 10870 OVERSEAS HIGHWAY MARATHON FL 33050-3455
1052884 THE MEDICINE CHEST 910 OLD CAMP RD BUILDING 170 THE VILLAGES FL 32162
1054799 WALGREENS #4481 3994 TYRONE BLVD N ST PETERSBURG FL 33709
1066415 WALGREENS 805 CAPE CORAL PKWY E CAPE CORAL FL 33904
1080249 WALGREENS #3854 15900 NW 27TH AVE OPA LOCKA FL 33054
1148003 WALGREENS #6330 2464 ROSWELL RD MARIETTA GA 30062
1816923 CVS PHARMACY 118 E NEW CIRCLE RD LEXINGTON KY 40505
2381135 WALGREENS #16254 1007 MEMORIAL RD HOUGHTON MI 49931-2485
2412978 KMART PHARMACY3405 10 W LAKE STREET MINNEAPOLIS MN 55408
2416178 FAIRVIEW RIDGES HOSPITAL PHARMACY 201 EAST NICOLLET BOULEVARD BURNSVILLE MN 55337
2420711 WALMART PHARMACY 10-1038 2103 STATE ST. N WASECA MN 56093
2420759 WALMART PHARMACY 10-1952 8450 UNIVERSITY AVENUE NE FRIDLEY MN 55432
2420848 CVS PHARMACY # 1001 13TH ST S VIRGINIA MN 55792
2420949 CVS PHARMACY # 1300 STATE HIGHWAY 55 NE BUFFALO MN 55313
2422169 ESSENTIA HEALTH BRAINERD PHARMACY 2024 S 6TH ST BRAINERD MN 56401
2423313 CUB PHARMACY 8421 LYNDALE AVE S BLOOMINGTON MN 55420
2425191 WALMART PHARMACY 10-3513 8101 OLD CARRIAGE COURT SHAKOPEE MN 55379
2425836 LUNDS & BYERLYS PHARMACY #51003 6228 PENN AVE S RICHFIELD MN 55423
2427690 CVS PHARMACY 17578 DODD BLVD LAKEVILLE MN 55044
2432805 ALLINA HEALTH HOME INFUSION THERAPY 4050 COON RAPIDS BLVD NW STE 123 COON RAPIDS MN 55433-2522
2433124 HY-VEE PHARMACY (1356) 16150 PILOT KNOB RD LAKEVILLE MN 55044-4105
2433629 CVS PHARMACY #17705 1300 W LAKE ST MINNEAPOLIS MN 55408-2763
2818790 MEDICINE MAN PHARMACY 748 MAIN ST NORTH BEND NE 68649
2993699 WALGREENS 2427 LAS VEGAS BLVD S LAS VEGAS NV 89104-2530
3128154 SHOPRITE PHARMACY 300 ROUTE 31 SOUTH WASHINGTON NJ 07882
3144475 CVS PHARMACY # 45 CENTRAL AVE CLARK NJ 07066
3429772 WALMART PHARMACY 10-2005 2420 SUPERCENTER DRIVE N.E. KANNAPOLIS NC 28083
3430369 BIOLOGICS INC 120 WESTON OAKS COURT CARY NC 27513
4518366 CVS PHARMACY # 409 VETERANS BLVD DEL RIO TX 78840
5117329 WALGREENS #10873 2830 N OAKLAND AVE MILWAUKEE WI 53211-3228
5120756 WALMART PHARMACY 10-1643 377 NORTH ROLLING MEADOWS DR FOND DU LAC WI 54935
5127635 WALGREENS #7966 849 WOODWARD AVE CHIPPEWA FALLS WI 54729
0352170 WALGREENS #1076 333 E HUNT HWY QUEEN CREEK AZ 85143-4495
0352865 WALMART PHARMACY 10-5369 1100 NORTH ESTRELLA PARKWAY GOODYEAR AZ 85338
0356558 FRYS FOOD AND DRUG 16380 W YUMA RD GOODYEAR AZ 85338
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
16 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
0802923 WALGREENS #11026 110 E DUPONT HWY MILLSBORO DE 19966
1013438 ACS PHARMACY 6251 CHANCELLOR DR ORLANDO FL 32859-9800
1065754 PUBLIX PHARMACY #0400 1500 PLACIDA RD BLDG C ENGLEWOOD FL 34223
1075402 WALGREENS #3606 6465 S TAMIAMI TRAIL SARASOTA FL 34231
1078369 WALGREENS #3894 1650 DUNLAWTON AVE PORT ORANGE FL 32127
1474446 WALGREENS #06270 1001 W BELMONT AVE CHICAGO IL 60657
1474597 WALMART PHARMACY 10-3210 2760 NO. DIRKSEN PKWY SPRINGFIELD IL 62702
2403222 ROSS WESTBANK PHARMACY 327 CEDAR AVE S MINNEAPOLIS MN 55454-1030
2420925 GUIDEPOINT PHARMACY 20 W MAIN ST CROSBY MN 56441-1422
2425165 CVS PHARMACY # 151 TYLER RD N RED WING MN 55066
2425242 THRIFTY WHITE PHARMACY #746 31 NORTH MAIN BAGLEY MN 56621
2427462 GILLETTE CHILDRENS SPECIALTY HEALTH 200 UNIVERSITY AVE E ST PAUL MN 55101
2428476 COBORNS PHARMACY #2037 225 33RD ST W HASTINGS MN 55033
2430077 WALGREENS #13163 18 SE 10TH ST GRAND RAPIDS MN 55744-3947
2430914 CVS PHARMACY # 8936 LYNDALE AVE, S. BLOOMINGTON MN 55420
2817344 WALMART PHARMACY 10-4209 2101 S. 11TH STREET NEBRASKA CITY NE 68410
3003883 WALGREENS 440 WEST ST KEENE NH 03431
4354762 REGIONAL HEALTH HOME PLUS PHARMACY353 FAIRMONT BLVD RAPID CITY SD 57701
4837071 WALMART PHARMACY 10-3265 2601 GEO. WASHINGTON MEM. HWY YORKTOWN VA 23693
5113496 SHOPKO PHARMACY 955 W CLAIREMONT AVE EAU CLAIRE WI 54701-6103
5116581 SHELL LAKE PHARMACY 108 4TH AVE W SHELL LAKE WI 54871
5130923 WALGREENS 10489 SR 27 HAYWARD WI 54843
5700112 TOTAL CARE PHARMACY 4900 LINTON BLVD STE 24 DELRAY BEACH FL 33445-6687
0119429 RITE AID PHARMACY 07108 25801 PERDIDO BEACH BOULEVARD ORANGE BEACH AL 36561-1340
0121652 PROVIDENCE MEDICAL OFFICE PHARMACY6701 AIRPORT BLVD MOBILE AL 36608
0134750 CVS PHARMACY # 3489 LOWERY PKWY FULTONDALE AL 35068
0304989 WALGREENS #02451 4220 N ORACLE RD TUCSON AZ 85705
0305032 WALGREENS #5505 3502 W CAMELBACK RD PHOENIX AZ 85019
0310639 WALGREENS #06128 19003 RH JOHNSON BLVD SUN CITY WEST AZ 85375
0312948 WALGREENS #04018 2345 E BASELINE RD GILBERT AZ 85234-2326
0320147 WALGREENS #2963 11545 E APACHE TRAIL APACHE JUNCTION AZ 85120-3522
0358829 FRYS FOOD AND DRUG 19403 N R H JOHNSON BLVD SUN CITY AZ 85375-4404
0528971 WALMART PHARMACY 10-1853 1231 SO. SANDERSON AVENUE HEMET CA 92545
1068572 WALMART PHARMACY 10-1847 4980 EAST SILVER SPRINGS BLVD OCALA FL 34470
1146821 WALGREENS #5485 2779 COBB PKWY KENNESAW GA 30152
1203354 LONGS DRUGS 86120 FARRINGTON HWY WAIANAE HI 96792
1240441 WALGREENS #12786 10 E KAMEHAMEHA AVE KAHULUI HI 96732-2415
2406331 CHILDRENS HOSP AND CLINICS OF MN 2525 CHICAGO AVE S MINNEAPOLIS MN 55404-4518
2420165 FAIRVIEW NORTHLAND PHARMACY ZIMME25945 GATEWAY DRIVE ZIMMERMAN MN 55398
2421662 CORAM CVS/SPECIALTY INFUSION SERVIC2345 WATERS DR MENDOTA HEIGHTS MN 55120
2423731 CVS PHARMACY # 1685 17TH AVE E SHAKOPEE MN 55379
2426129 WALGREENS 750 MANKATO AVE WINONA MN 55987
2426977 SAMS PHARMACY 10-6427 3410 NORTHWEST 55TH STREET ROCHESTER MN 55901
2427044 COBORNS PHARMACY #2033 7900 SUNWOOD DR NW RAMSEY MN 55303
2429353 ESSENTIA HEALTH SANDSTONE 109 COURT AVENUE SOUTH SANDSTONE MN 55072
2431649 COSTCO PHARMACY #1122 13650 ELDER DRIVE BAXTER MN 56425-2720
2432007 STERLING 700 DIVISION ST NORTHFIELD MN 55057-2497
2432502 CVS PHARMACY # 1215 E SUPERIOR ST DULUTH MN 55802-2218
2817875 WALGREENS #12854 502 S 11TH ST NEBRASKA CITY NE 68410-2728
3341889 GIDEONS DRUGS INC 1385 BROADWAY NEW YORK NY 10018
3715072 ALANS PHARMACY 1721 W 6TH AVE STILLWATER OK 74074-4200
3951084 CVS PHARMACY 1301 RHAWN ST PHILADELPHIA PA 19111
4532417 CVS PHARMACY 16515 LEXINGTON BLVD SUGARLAND TX 77479
4549602 HEB PHARMACY 5313 SARATOGA CORPUS CHRISTI TX 78413
4929088 CVS PHARMACY # 665 SLEATER KINNEY RD SE LACEY WA 98503
5127875 WALGREENS #1937 1106 W CLAIREMONT AV EAU CLAIRE WI 54701
5719060 WINN DIXIE 820 OLD CAMP ROAD THE VILLAGES FL 32162
0305929 WALGREENS #7828 6002 E MAIN ST MESA AZ 85205-8928
0322355 WALGREENS #3191 10865 N TATUM BLVD PHOENIX AZ 85028
0323371 CVS PHARMACY # 10555 N ORACLE RD ORO VALLEY AZ 85737
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
17 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
0325313 WALGREENS #5453 6501 E GREENWAY RD SCOTTSDALE AZ 85254
0325781 WALGREENS #5775 8309 W GLENDALE AVE GLENDALE AZ 85305
0353728 CVS PHARMACY 4748 E SUNRISE TUCSON AZ 85718
0356231 WALMART PHARMACY 10-5768 800 E SOUTHERN AVE TEMPE AZ 85282-5225
0418625 WALGREENS #3411 3631 N CENTRAL AVE HOT SPRINGS AR 71913
0533100 WALMART PHARMACY 10-1862 1366 S RIVERSIDE AVE RIALTO CA 92376-7608
0613631 ROCKY MOUNTAIN PHARMACY 455 E WONDERVIEW AVE B1 ESTES PARK CO 80517
0621715 WALGREENS #12683 2870 28TH ST BOULDER CO 80301-1247
1004629 CVS PHARMACY 8001 9TH ST N ST PETERSBURG FL 33702
1021423 BRADYS PHARMACY 6810 STIRLING RD DAVIE FL 33024
1043342 WALGREENS #4568 10881 W OAKLAND PARK BLVD SUNRISE FL 33351
1059117 CVS PHARMACY 9204 CORTEZ BLVD WEEKI WACHEE FL 34613
1071416 WALGREENS #3046 2295 E BAY DRIVE LARGO FL 33771
1083120 WALGREENS #4176 399 N CONGRESS AVE BOYNTON BEACH FL 33426
1085364 CVS PHARMACY # 8151 DR MARTIN LUTHER KING ST N SAINT PETERSBURG FL 33702
1087217 COSTCO PHARMACY 7171 CYPRESS LAKE DRIVE FORT MYERS FL 33907
1087306 WALGREENS #5432 1581 BELLA CRUZ DR THE VILLAGES FL 32159-8970
1090137 WALGREENS #5581 6314 N 9TH AVE PENSACOLA FL 32504
1096634 CVS PHARMACY 51 MISSOURI AVE N LARGO FL 33770
1201172 LONGS DRUGS 70 E KAAHUMANU AVE KAHULUI HI 96732
1203304 LONGS DRUGS 645 ALEKA LOOP KAPAA HI 96746-2099
1240302 LONGS DRUGS 55 KIOPAA ST PUKALANI HI 96768
1467617 WALGREENS #03780 3035 BOOK ROAD NAPERVILLE IL 60564
1477606 WALGREENS #07179 2 E ROOSEVELT RD CHICAGO IL 60605
1480641 WALGREENS #15525 201 E HURON STREET CHICAGO IL 60611
1528403 WALMART PHARMACY 10-1665 4801 W CLARA LANE MUNCIE IN 47304
1621590 WALMART PHARMACY 10-3590 3101 FLOYD BLVD SIOUX CITY IA 51108
1717238 WALGREENS #6113 1625 S WEBB RD WICHITA KS 67207
1827104 RX CROSSROADS 5101 JEFF COMMERCE DR LOUISVILLE KY 40219-3336
1929489 WALGREENS #5551 619 DECATUR ST NEW ORLEANS LA 70130
2224854 CVS PHARMACY 36 WHITE ST CAMBRIDGE MA 02140
2360206 WALGREENS #4992 15450 MICHIGAN AVE DEARBORN MI 48126
2362731 CVS PHARMACY 1550 LAKE RD SE GRAND RAPIDS MI 49506
2408753 FAMILY FRESH MARKET PHARMACY 3331 612 S MINNESOTA AVE SAINT PETER MN 56082
2410316 GORDYS PHARMACY 320 SUMMIT AVE CENTER CITY MN 55012
2416318 WALGREENS #10187 900 MAIN AVE MOORHEAD MN 56560-2860
2417144 SHOPKO PHARMACY 1850 E MADISON AVE MANKATO MN 56001-5448
2417245 NORTHFIELD PHARMACY 601 S WATER ST NORTHFIELD MN 55057-2434
2419465 WALMART PHARMACY 10-1609 100 SE 29TH ST GRAND RAPIDS MN 55744-4043
2419530 WEBER & JUDD - SPRING VALLEY 503 N PARK DR SPRING VALLEY MN 55975-9300
2420545 WALMART PHARMACY 10-1855 12195 SINGLETREE LANE EDEN PRAIRIE MN 55344
2424151 CUB PHARMACY 2410 S POKEGAMA AVE GRAND RAPIDS MN 55744
2424339 SAMS PHARMACY 10-4736 14940 FLORENCE TRAIL APPLE VALLEY MN 55124
2425014 ELY COMMUNITY PHARMACY 328 W CONAN ST ELY MN 55731
2425204 WALMART PHARMACY 10-3534 295 TYLER ROAD SOUTH RED WING MN 55066
2425848 HY-VEE PHARMACY (1848) 1230 NORTH STATE STREET WASECA MN 56093
2426155 CUYUNA REGIONAL MEDICAL CENTER 320 E MAIN ST CROSBY MN 56441
2427397 FAIRVIEW PHARMACY UNIVERSITY VILLAG2545 UNIVERSITY AVENUE SOUTHEAST MINNEAPOLIS MN 55414
2429517 CVS PHARMACY #08930 657 E MAIN ST ANOKA MN 55303
2430370 OPTION CARE 1000 S BENTON DR UNIT 405 SAUK RAPIDS MN 56379-1228
2430483 WALGREENS 1609 KENWOOD AVENUE DULUTH MN 55811
2432792 MEDICAL PHARMACY MOORHEAD AZOOL 950 40TH AVE S MOORHEAD MN 56560
2433706 HY-VEE PHARMACY (1562) 1451 ADAMS ST S SHAKOPEE MN 55379-2697
2625082 WALGREENS #2151 5550 S GRAND BLVD ST LOUIS MO 63111
2629371 WALGREENS #3338 1 S KINGSHIGHWAY CAPE GIRARDEAU MO 63703-5742
3007083 HANNAFORD FOOD AND DRUG 481 WEST STREET KEENE NH 03431
3061594 CVS PHARMACY #10463 118 CENTRAL AVE DOVER NH 03820
3149817 PASSAIC VALLEY MEDICAL PHARMACY 1225 MCBRIDE AVE WOODLAND PARK NJ 07424
3502083 ALTRU RETAIL PHARMACY 1200 S COLUMBIA RD GRAND FORKS ND 58201
3504330 CVS PHARMACY 1321 19TH AVE NORTH FARGO ND 58102
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
18 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
3669833 CVS PHARMACY 2160 N HIGH ST COLUMBUS OH 43201
3726594 WALMART PHARMACY 10-5863 7520 E RENO AVE MIDWEST CITY OK 73110-4312
3978559 WAL-MART PHARMACY 10-2888 100 NO LONDONDERRY SQUARE PALMYRA PA 17078
4434609 CVS PHARMACY # 1816 GUNBARREL RD CHATTANOOGA TN 37421
4529496 WALGREENS #7674 905 CRYSTAL FALLS PKWY LEANDER TX 78641
4544486 WALGREENS #10551 1701 W BUSINESS 83 WESLACO TX 78596-5632
4563210 CVS PHARMACY 4600 SOUTHWEST PKWY WICHITA FALLS TX 76310
4821004 WALMART PHARMACY 10-1023 1140 EAST STUART DRIVE GALAX VA 24333
4838299 CVS PHARMACY # 5115 LEESBURG PIKE FALLS CHURCH VA 22041
4841739 WALGREENS #10453 2400 GEORGE WASHINGTON MEMORIAL HWY YORKTOWN VA 23693
4909668 MULTICARE MEDICAL CENTER PHARMACY 315 MARTIN LUTHER KING JR WAY TACOMA WA 98405-4234
4919861 PROVIDENCE MEDICAL CENTER PHARMACY1321 COLBY AVE EVERETT WA 98201-1684
4936083 MOUNT BAKER PP MOUNT VERNON 1805 E DIVISION ST MOUNT VERNON WA 98274-4632
5101124 CONSUMER PRESCRIPTION CENTER 2310 W COLLEGE AVE APPLETON WI 54914
5124449 CVS PHARMACY # 4777 S 27TH ST GREENFIELD WI 53221
5128372 WALGREENS #9514 121 PINE AVE W MENOMONIE WI 54751
5616543 COSTCO PHARMACY 1540 FROOM RANCH WAY SAN LUIS OBISPO CA 93405
5620338 CVS PHARMACY 2530 GLENDALE BOULEVARD LOS ANGELES CA 90039
5630149 WALGREENS 2465 E PALM CANYON DR PALM SPRINGS CA 92264-4872
5645366 WALGREENS #15539 39000 BOB HOPE DR RANCHO MIRAGE CA 92270
5712383 PUBLIX PHARMACY #1431 29 BLAKE BLVD CELEBRATION FL 34747-5482
5908756 WALGREENS #15381 1921 S 77 SUNSHINE STRIP HARLINGEN TX 78550
5910751 CVS PHARMACY # 300 E COMMERCE ST SAN ANTONIO TX 78205-2922
0132605 WALGREENS #2203 3892 ATLANTA HWY MONTGOMERY AL 36109
0200686 DENALI PHARMACY 1650 COWLES ST FAIRBANKS AK 99701-5998
0320781 WALGREENS #3132 2415 E UNION HILLS DR PHOENIX AZ 85050
0323701 WALGREENS #4742 8310 W DEER VALLEY RD PEORIA AZ 85382
0353641 CVS PHARMACY 10653 N SCOTTSDALE SCOTTSDALE AZ 85254
0353817 CVS PHARMACY 240 W CONTINENTAL RD GREEN VALLEY AZ 85614
0354453 CVS PHARMACY # 13870 W GREENWAY RD SURPRISE AZ 85374
0520850 SAN YSIDRO PHARMACY INC 1498 EAST VALLEY RD SANTA BARBARA CA 93108
0576085 WALGREENS 22930 S WESTERN AVE TORRANCE CA 90501
0613237 CITY MARKET PHARMACY 300 DILLON RIDGE RD DILLON CO 80435
0617881 WALGREENS #6987 355 S WILCOX ST CASTLE ROCK CO 80104
0620991 WALGREENS #12918 4745 ARAPAHOE AVE BOULDER CO 80303-1080
0711855 WALGREENS #5134 540 BUSHY HILL ROAD SIMSBURY CT 06070
0720094 WALGREENS #1451 1083 BOSTON POST RD MILFORD CT 06460
1002625 CVS PHARMACY 13991 N CLEVELAND AVENUE FT MYERS FL 33903
1031741 CVS PHARMACY # 8040 MEDITERRANEAN DR ESTERO FL 33928
1041261 CVS PHARMACY # 3200 ROLLING OAKS BLVD KISSIMMEE FL 34747
1043708 CVS PHARMACY 7001 ESTERO BLVD FT MYERS BEACH FL 33931
1055878 WALMART PHARMACY 10-1004 5315 CORTEZ RD WEST BRADENTON FL 34210
1062710 CVS PHARMACY 611 MANATEE AVE HOLMES BEACH FL 34217
1067380 PUBLIX PHARMACY #1287 17179 TAMIAMI TRAIL NORTH PORT FL 34287
1085263 WALGREENS #4593 2200 PALM BEACH LAKES BLVD WEST PALM BEACH FL 33409
1095808 WALGREENS #6913 15900 SUMMERLIN RD FORT MYERS FL 33908
1203289 LONGS DRUGS 78-6831 ALII DR KAILUA KONA HI 96740
1203378 COSTCO PHARMACY 540 HALEAKALA HIGHWAY KAHULUI HI 96732
1464863 CVS PHARMACY # 2209 HOWARD ST EVANSTON IL 60202
1523667 WALGREENS #13949 6001 CENTRAL AVE PORTAGE IN 46368-3506
1623366 WALMART PHARMACY 10-4256 534 SO DUFF AVE AMES IA 50010
1809613 KENTUCKY CLINIC PHARMACY 740 SOUTH LIMESTONE ST LEXINGTON KY 40536-0284
1812329 CVS PHARMACY 144 NORTH HWY 27 SOMERSET KY 42503-1732
1931105 WALGREENS 100 W JUDGE PEREZ DR CHALMETTE LA 70043
2008224 WALGREENS 45 GROVE ST AUGUSTA ME 04330
2340634 CVS PHARMACY # 31250 BECK RD NOVI MI 48377
2406595 NORTHPOINT HEALTH & WELLNESS CENTE 1313 PENN AVE N MINNEAPOLIS MN 55411
2411128 UMMC FAIRVIEW RIVERSIDE CAMPUS PHA2450 RIVERSIDE AVENUE MINNEAPOLIS MN 55454
2414287 TRUMM DRUG CLINIC PHARMACY 610 30TH AVE WEST ALEXANDRIA MN 56308-0397
2417461 CUB PHARMACY 300 E TRAVELERS TRAIL BURNSVILLE MN 55337
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
19 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
2420773 CASH WISE PHARMACY #3011 1020 HWY 15 S HUTCHINSON MN 55350
2421193 TRUMM DRUG ELBOW LAKE 11 CENTRAL AVE S ELBOW LAKE MN 56531
2422296 HY-VEE PHARMACY #2 (1394) 2010 ADAMS STREET MANKATO MN 56001
2423274 CUB PHARMACY 14133 EDGEASTWOOD DR BAXTER MN 56425
2423298 CUB PHARMACY 4445 N NATHAN LN PLYMOUTH MN 55442
2426357 WALGREENS #9065 401 5TH ST W NORTHFIELD MN 55057
2427436 MERWIN IV AND SPECIALTY PHARMACY 1811 OLD HIGHWAY 8 NW SUITE C NEW BRIGHTON MN 55112-1828
2429404 COBORN'S PHARMACY #2039 1500 ELM ST E SAINT JOSEPH MN 56374
2429860 WALGREENS #12044 8240 FLYING CLOUD DR EDEN PRAIRIE MN 55344-5316
2429961 WALGREENS #12509 700 30TH AVE S MOORHEAD MN 56560
2429997 WALGREENS #13903 101 NORTH MAIN STREET PARK RAPIDS MN 56470-1511
2430344 LAKEVIEW MEMORIAL HOSPITAL ASSOC I 927 WEST CHURCHILL ST STILLWATER MN 55082
2430534 CVS PHARMACY # 1175 E MADISON AVE MANKATO MN 56001-5227
2430748 WALGREENS #13842 9 CENTRAL AVE E SAINT MICHAEL MN 55376-9520
2431031 GRAND MARAIS PHARMACY 425 W HIGHWAY 61 GRAND MARAIS MN 55604-0365
2431132 SANFORD BEMIDJI MEDICAL CENTER 1300 ANNE ST NW BEMIDJI MN 56601-5103
2431714 MAYO CLINIC PHARMACY-RED WING 701 HEWITT BLVD RED WING MN 55066
2432374 ALLINA HEALTH REGINA HOSPITAL 1175 NININGER RD HASTINGS MN 55033-1098
2433150 COBORN'S PHARMACY #2046 209 6TH AVE NE ISANTI MN 55040-3220
2617302 FAMILY PHARMACY #4 18192 BUSINESS 13 STE A BRANSON WEST MO 65737
2629989 SCHNUCKS PHARMACY 1020 LOUGHBOROUGH ST LOUIS MO 63111
2631869 LAKELAND PHARMACY 18565 BUSINESS 13 BRANSON WEST MO 65737
2700537 MSU STUDENT HEALTH SERVICE PHARMACMSU STUDENT HEALTH SERVICE RX BOZEMAN MT 59715-0002
2816520 WALGREENS #07563 8989 W DODGE RD OMAHA NE 68114
2818245 CVS PHARMACY # 06733 1919 N 90TH ST OMAHA NE 68114-1316
2906470 WALMART PHARMACY 10-2593 2310 E SERENE AVENUE LAS VEGAS NV 89123
2907268 WALGREENS #07164 101 E LAKE MEAD PKWY HENDERSON NV 89015
3061443 UNH HEALTH SERVICE PHARMACY 4 PETTEE BROOK LANE DURHAM NH 03824-2308
3306277 DUANE READE 2864 BROADWAY NEW YORK NY 10025
3355523 WALGREENS #9937 10 PROSPECT ST JAMESTOWN NY 14701
3424998 WALMART PHARMACY 10-1179 60 AIRPORT RD ARDEN NC 28704-9405
3463988 CORDELE PHARMACY 3809 BEAM RD STE H CHARLOTTE NC 28217-2852
3842538 BROADWAY APOTHECARY 1515 OAK ST EUGENE OR 97401
4223462 HAWTHORNE SUNSET PHARMACY 2854 SUNSET BLVD WEST COLUMBIA SC 29169
4225341 WALGREENS #1072 1120 N MAIN ST SUMMERVILLE SC 29483
4229870 WALMART PHARMACY 10-5705 545 GARDEN CITY CONNECTOR MURRELLS INLET SC 29576-7847
4300935 SDSU JACKRABBIT PHARMACY 1440 NORTH CAMPUS DR BROOKINGS SD 57007
4352984 CVS PHARMACY # 3600 S LOUISE AVE SIOUX FALLS SD 57106
4353962 WALGREENS #10572 100 E SIOUX AVE PIERRE SD 57501-3196
4559007 WALMART PHARMACY 10-0395 2410 EAST EXPRESSWAY 83 MISSION TX 78572
4563979 HEB PHARMACY 2250 BOCA CHICA BLVD BROWNSVILLE TX 78520
4594051 WALGREENS #3504 6393 BABCOCK ROAD SAN ANTONIO TX 78240
4696968 WALGREENS #6281 1300 E DRAPER PKWY DRAPER UT 84020
5105184 JAMES PHARMACY 337 E LASALLE AVE BARRON WI 54812-1502
5125504 JOHNSON DRUG AT ARMC 265 E GRIFFIN ST AMERY WI 54001
5126429 CVS PHARMACY # 9400 STATE ROAD 16 ONALASKA WI 54650
5128031 HUDSON HOSPITAL 405 STAGELINE RD HUDSON WI 54016
5134084 BURNETT MEDICAL CENTER 257 W SAINT GEORGE AVE GRANTSBURG WI 54840-7827
5601883 WALGREENS 8005 EL CAMINO REAL ATASCADERO CA 93422-5211
5627572 WALGREENS 2331 S ALTANTIC BLVD MONTEREY PARK CA 91754-6805
5636393 WALGREENS 1320 ENCINITAS BLVD ENCINITAS CA 92024-2844
5653793 CVS PHARMACY # 12746 W JEFFERSON BLVD STE 3160 PLAYA VISTA CA 90094
5700679 WALGREENS 1120 TAMIAMI TRL N NOKOMIS FL 34275-2158
5723766 WALMART PHARMACY 10-6937 2150 TAMIAMI TRL PORT CHARLOTTE FL 33948-2136
5802803 CUREWAYS 2201 AMSTERDAM AVE NEW YORK NY 10032-2512
5908770 CVS PHARMACY # 10715 BANDERA RD SAN ANTONIO TX 78250-6808
0000243
0000245
0132112 WALGREENS #7746 6680 ATLANTA HWY MONTGOMERY AL 36117
0228189 WALGREENS 1470 W NORTHERN LIGHTS BLVD ANCHORAGE AK 99503-3663
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
20 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
0303191 WALGREENS #03464 3402 N CENTRAL AVE PHOENIX AZ 85012-2202
0311059 WALGREENS # 13822 550 N SILVERBELL RD TUCSON AZ 85745
0315956 FRYS FOOD AND DRUG 1835 E GUADALUPE RD TEMPE AZ 85283
0318914 WALGREENS #06060 16415 E PALISADES BLVD FOUNTAIN HILLS AZ 85268
0319877 WALGREENS #2851 7000 N 16TH ST PHOENIX AZ 85020
0320084 WALGREENS #2771 1305 S GREENFIELD MESA AZ 85206
0320349 WALGREENS #3048 9050 W UNION HILLS PEORIA AZ 85382
0320870 COSTCO PHARMACY 3901 WEST COSTCO DRIVE TUCSON AZ 85741
0321430 CVS PHARMACY # 1818 E BASELINE RD TEMPE AZ 85283
0328054 WALMART PHARMACY 10-2767 4505 EAST MCKELLIPS ROAD MESA AZ 85215
0328535 MAYO HOSPITAL OUTPATIENT PHARMACY 5777 E MAYO BLVD PHOENIX AZ 85054
0352738 CVS PHARMACY 1850 W DUNLAP AVE PHOENIX AZ 85021
0353350 WALGREENS #9953 7885 E SPEEDWAY BLVD TUCSON AZ 85710
0356116 WALGREENS #2209 11420 S FORTUNA RD YUMA AZ 85367
0356471 WALGREENS #12335 10825 E BASELINE RD. MESA AZ 85209
0357625 SUN CITY PHARMACY INC 9133 W THUNDERBIRD RD STE 101 PEORIA AZ 85381
0505694 WALGREENS 1591 GEER ROAD TURLOCK CA 95380
0510710 WALGREENS 1800 CONCORD AVE CONCORD CA 94520
0511394 RITE AID PHARMACY 06293 1605 SOUTH SAN JACINTO AVENUE SAN JACINTO CA 92583-5181
0520797 PREMIER PHARMACY SERVICES 410 CLOVERLEAF DR BALDWIN PARK CA 91706-6511
0574005 CVS PHARMACY 3964A MISSOURI FLAT RD PLACERVILLE CA 95667
0600824 KING SOOPERS PHARMACY 1155 E 9TH AVE DENVER CO 80218-3438
0612273 WALGREENS #1769 2000 EAST COLFAX DENVER CO 80206
0615673 WALGREENS #4469 15301 E MISSISSIPPI AVE AURORA CO 80017
0616916 SAFEWAY PHARMACY #1614 560 CORONA ST DENVER CO 80218
0623048 WALGREENS 3555 COLORADO BLVD DENVER CO 80205-3813
0902723 CVS PHARMACY 1637 P ST NW WASHINGTON DC 20036
1000164 WALGREENS 4320 26TH ST W BRADENTON FL 34205
1002055 WALGREENS 8706 W HILLSBOROUGH AVE TAMPA FL 33615
1003742 WALGREENS 4220 MANATEE AVE W BRADENTON FL 34205-1721
1004770 CVS PHARMACY 6204 14TH ST WEST BRADENTON FL 34207
1005227 CVS PHARMACY 4292 N ATLANTIC AVE COCOA BEACH FL 32931
1007752 WALGREENS #6407 99551 OVERSEAS HWY KEY LARGO FL 33037
1033846 WALGREENS 12749 S CLEVELAND AVE FORT MYERS FL 33907-3806
1050929 WALGREENS #10829 611 BURNT STORE RD S CAPE CORAL FL 33991-1708
1050955 CVS PHARMACY 130 SCENIC GULF DR MIRAMAR BEACH FL 32550
1062746 PUBLIX PHARMACY #0376 101437 OVERSEAS HIGHWAY KEY LARGO FL 33037
1080251 WALGREENS #4164 12100 S APOPKA VINELAND RD LAKE BUENA VISTA FL 32836
1094921 WALGREENS #6797 3799 MURRELL RD ROCKLEDGE FL 32955
1142443 PUBLIX PHARMACY #0559 2774 N COBB PKWY KENNESAW GA 30152
1148801 WALGREENS #6138 2065 S HAIRSTON RD DECATUR GA 30035
1148940 WALGREENS #6098 125 JOHNNY MERCER BLVD SAVANNAH GA 31410
1149031 CVS PHARMACY 1380 WOODSTOCK RD ROSWELL GA 30075
1307289 WALGREENS 335 W APPLEWAY AVE COEUR D ALENE ID 83814
1406835 WALGREENS #07419 1601 N MAIN ST WHEATON IL 60187
1438111 WALGREENS #03433 2560 WEST GOLF ROAD HOFFMAN ESTATES IL 60169-1114
1451501 WALGREENS #1504 10639 SOUTH CICERO OAK LAWN IL 60453
1468417 WALGREENS #04599 704 CAMBRIDGE BLVD OFALLON IL 62269
1468582 WALGREENS #04540 901 W TOUHY PARK RIDGE IL 60068
1474686 WALGREENS #5962 4820 N CUMBERLAND AVE NORRIDGE IL 60706
1474713 WALGREENS #05542 8001 N MILWAUKEE AVE NILES IL 60714
1474799 CVS PHARMACY 2045 PLUM GROVE RD ROLLING MEADOWS IL 60008
1474802 CVS PHARMACY 105 S WABASH CHICAGO IL 60603
1477632 CVS PHARMACY 250 WEST 144TH ST RIVERDALE IL 60827
1503463 CVS PHARMACY 265 SOUTH SCATTERFIELD ROAD ANDERSON IN 46012
1606447 AMBULATORY CARE PHARMACY 200 HAWKINS DR IOWA CITY IA 52242
1610016 IOWA STATE UNIVERSITY 1042 THIELEN STUDENT HEALTH CNTR AMES IA 50011-2029
1611006 HY-VEE PHARMACY (1759) 8701 DOUGLAS AVENUE URBANDALE IA 50322
1616804 WALGREENS #12108 2719 GRAND AVE AMES IA 50010
1622580 CVS PHARMACY 201 S CLINTON IOWA CITY IA 52240
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
21 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
1623619 WALGREENS #11759 2639 AVENUE L FORT MADISON IA 52627-3840
1624700 WALGREENS 1900 HAMILTON BLVD SIOUX CITY IA 51104-4149
1624926 WALGREENS 625 PACHA PKWY NORTH LIBERTY IA 52317-4831
1707629 UNIVERSITY OF KANSAS HOSPITAL RETAI 3901 RAINBOW BLVD KANSAS CITY KS 66160
1715210 WALGREENS #3055 3421 W 6TH ST LAWRENCE KS 66049
2002943 CVS PHARMACY 770 ROOSEVELT TRAIL ROUTE 302 WINDHAM ME 04062
2004682 HANNAFORD FOOD AND DRUG 71 COLONIAL DRIVE STANDISH ME 04084
2005278 WALMART PHARMACY 10-2046 201 CIVIC CENTER DR AUGUSTA ME 04330-8033
2006597 RITE AID PHARMACY 04273 720 CENTRAL STREET MILLINOCKET ME 04462-1800
2140185 HARRIS TEETER PHARMACY #404 4805 BATTERY LN BETHESDA MD 20814-2701
2239552 WALMART PHARMACY 10-2902 121 WORCESTER ROAD FRAMINGHAM MA 01701
2366424 WALGREENS #7206 5709 S TELEGRAPH RD DEARBORN HEIGHTS MI 48125
2369874 CVS PHARMACY 5756 CLARKSTON RD INDEPENDENCE TOWNSHIP MI 48348
2370827 WALMART PHARMACY 10-5444 10305 COUNTRY CLUB ROAD IRONWOOD MI 49938
2400125 WALGREENS #1737 200 W LAKE ST MINNEAPOLIS MN 55408
2412790 WHITE DRUG #107 707 HIGHWAY 33 SOUTH SUITE 12 CLOQUET MN 55720
2413766 THRIFTY WHITE DRUG #722 321 WEST MAIN STREET MARSHALL MN 56258
2414441 PARK NICOLLET PHARMACY BLOOMINGTO 5320 HYLAND GREENS DRIVE BLOOMINGTON MN 55437
2416875 ONAMIA DRUG 516 MAIN ST ONAMIA MN 56359-0249
2419047 THE MEDICINE SHOPPE PHARMACY 329 E HWY 12 LITCHFIELD MN 55355-2260
2422549 HY-VEE PHARMACY #1 (1547) 500 CROSSROADS DR SW ROCHESTER MN 55904
2424137 CUB PHARMACY 1021 15TH AVE SE ROCHESTER MN 55904
2424454 CUB PHARMACY 1200 S RIVERFRONT DR MANKATO MN 56001
2424543 CENTRACARE PHARMACY HEALTH PLAZA 1900 CENTRACARE CIRCLE ST CLOUD MN 56303
2424973 OPTION CARE 2750 ARTHUR ST ROSEVILLE MN 55113
2424985 CUB PHARMACY 417 8TH AVE NE BRAINERD MN 56401
2425153 CVS PHARMACY # 2505 1ST ST S WILLMAR MN 56201
2425709 CUB PHARMACY 23800 STATE HWY 7 SHOREWOOD MN 55331
2426270 WALMART PHARMACY 10-5397 955 FRONTENAC DRIVE WINONA MN 55987
2426282 WALGREENS #9095 125 18TH ST SE OWATONNA MN 55060
2426458 LUNDS & BYERLYS PHARMACY #15014 12880 ELM CREEK BLVD MAPLE GROVE MN 55369
2426838 COBORNS PHARMACY #2008 705 COUNTY ROAD 75 CLEARWATER MN 55320
2427450 ST JOSEPHS MEDICAL CENTER 523 N 3RD ST BRAINERD MN 56401
2428046 GENOA, A QOL HEALTHCARE COMPANY, LL800 TRANSFER RD STE 35 ST PAUL MN 55114-1414
2428197 GLENCOE REGIONAL HEALTH SERVICES 1805 HENNEPIN AVE NO GLENCOE MN 55336
2429125 WALGREENS 1705 COMMERCE DR NORTH MANKATO MN 56003
2429466 WALGREENS #11374 1023 1ST AVE NE LITTLE FALLS MN 56345-3336
2429757 WALGREENS #12434 2499 HIGHWAY 7 EXCELSIOR MN 55331-9701
2430306 WALGREENS #13463 1112 CIVIC CENTER DR NW ROCHESTER MN 55901-1843
2430318 GRAND ITASCA CLINIC AND HOSPITAL 1601 GOLF COURSE RD GRAND RAPIDS MN 55744-8648
2430471 HEALTHPARTNERS 8170 PHARMACY 8170 33RD AVE S BLOOMINGTON MN 55425
2430560 WINONA CLINIC PHARMACY 859 MANKATO AVE WINONA MN 55987-6435
2430697 ESSENTIA HEALTH TWO HARBORS PHARM802 11TH ST STE C TWO HARBORS MN 55616
2431118 WALGREENS 2500 WINNETKA AVE N GOLDEN VALLEY MN 55427-3569
2431168 ESSENTIA HEALTH BAXTER PHARMACY 13060 ISLE DR BAXTER MN 56425-8331
2431283 LAKE VIEW PHARMACY 1010 4TH STREET TWO HARBORS MN 55616-1200
2431738 WALMART PHARMACY 10-3102 300 21ST AVE N PRINCETON MN 55371
2432273 LEWIS FAMILY DRUG #77 1805 MINNESOTA AVE STE 2 BENSON MN 56215-1299
2432538 ESSENTIA HEALTH - ST JOSEPH'S EMILY C20918 COUNTY ROAD 1 EMILY MN 56447-4045
2432881 CVS PHARMACY # 2312 BEMIDJI AVE N BEMIDJI MN 56601-2318
2433011 WACONIA CLINIC PHARMACY 430 HWY 5 WEST WACONIA MN 55387
2433047 GENOA, A QOL HEALTHCARE COMPANY, LL166 4TH ST E STE 244 SAINT PAUL MN 55101-1421
2433213 HY-VEE PHARMACY (1040) 9409 ZANE AVE N BROOKLYN PARK MN 55443-1814
2433326 PRORX PHARMACY 621 MARIE AVE SOUTH SAINT PAUL MN 55075-2039
2500343 CVS PHARMACY 212 W PARK AVE GREENWOOD MS 38930
2639081 CVS PHARMACY #04850 2715 E BATTLEFIELD ST SPRINGFIELD MO 65804-3981
2642785 CVS PHARMACY # 10418 200 JUNGERMANN RD SAINT PETERS MO 63376-5347
2782971 CVS PHARMACY 115 NORTH 19TH AVENUE BOZEMAN MT 59718-4072
2970413 WALGREENS #05014 7845 W FLAMINGO RD LAS VEGAS NV 89147
3005421 RITE AID PHARMACY 10295 5 MILL ROAD DURHAM NH 03824-3046
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
22 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
3060744 CVS PHARMACY # 46 ASH BROOK RD KEENE NH 03431
3212862 WALGREENS #16391 500 WALTER STREET ALBUQUERQUE NM 87102
3358454 WALGREENS 1032 GATES AVE BROOKLYN NY 11221
3363518 RITE AID PHARMACY 10852 635 PITTSFORD VICTOR ROAD PITTSFORD NY 14534
3422362 CVS PHARMACY 773 RUSS AVE WAYNESVILLE NC 28786
3422742 MEDICAL CENTER PHARMACY 509 BILTMORE AVE ASHEVILLE NC 28801-4601
3423124 CVS PHARMACY 7205 KNIGHTDALE BLVD KNIGHTDALE NC 27545
3426714 WALMART PHARMACY 10-1452 3209 PINEVILLE MATTHEWS RD CHARLOTTE NC 28226
3432539 WNC COMMUNITY HEALTH SVCS OMC 257 BILTMORE AVE ASHEVILLE NC 28801-4120
3440637 WALGREENS 1200 S CROATAN HWY KILL DEVIL HILLS NC 27948
3500697 SANFORD PHARMACY SOUTH UNIVERSITY 1720 S UNIVERSITY DR FARGO ND 58103
3504912 THRIFTY WHITE PHARMACY #75 387 11TH ST S STE 2 WAHPETON ND 58075-4653
3729160 ASPCARES 3405 NW EXPRESSWAY OKLAHOMA CITY OK 73112
3814969 WALGREENS #7373 111 UNION AVE GRANTS PASS OR 97527
3843251 CVS PHARMACY # 9000 SE SUNNYSIDE RD CLACKAMAS OR 97015
3901306 RITE AID PHARMACY 10954 1125 FREEPORT ROAD PITTSBURGH PA 15238
3968673 RITE AID PHARMACY 10937 623 SMITHFIELD STREET PITTSBURGH PA 15222
4222206 WALGREENS #4813 11 PALMETTO BAY RD HILTON HEAD SC 29928
4304236 WALMART PHARMACY 10-1538 2233 6TH ST BROOKINGS SD 57006
4353683 HY-VEE PHARMACY (1039) 790 22ND AVENUE SOUTH BROOKINGS SD 57006
4400141 WALGREENS #586 2 N MAIN ST MEMPHIS TN 38103
4430322 WALMART PHARMACY 10-0687 2542 N MAIN ST CROSSVILLE TN 38555-8890
4434712 WALGREENS #5474 500 S WILLOW AVE COOKEVILLE TN 38501
4517237 WALGREENS #6390 1015 N TOWN EAST BLVD MESQUITE TX 75150
4533382 WALGREENS #9205 1309 SH 35 N ROCKPORT TX 78382
4540476 WALGREENS #9763 4515 CAMP BOWIE BLVD FORT WORTH TX 76107
4548787 CVS PHARMACY # 3061 WILDFLOWER DR BRYAN TX 77802
4549400 WALGREENS #11672 1673 HWY 100 PORT ISABEL TX 78578-2806
4551138 WALGREENS #11519 2007 S GOLIAD ST ROCKWALL TX 75087-4801
4551277 RITE CARE PHARMACY 7560 GREENVILLE AVENUE DALLAS TX 75231
4553409 CVS PHARMACY 800 W OLD SETTLERS BLVD ROUND ROCK TX 78681
4602757 UNIVERSITY OF UTAH OUTPATIENT PHARM50 N MEDICAL DR SALT LAKE CITY UT 84132-0001
4828476 FARM FRESH PHARMACY 115 NORGE LN WILLIAMSBURG VA 23188
4838857 CVS PHARMACY # 4310 FORTUNA CENTER PLZ DUMFRIES VA 22025
4923062 WALGREENS #5913 7905 N DIVISION ST SPOKANE WA 99208
4927628 WALGREENS #5598 6807 EVERGREEN WAY EVERETT WA 98203
4930132 WALGREENS #06614 20812 BOTHELL EVERETT HWY BOTHELL WA 98021
4931689 WALGREENS #9423 23003 PACIFIC HWY S DES MOINES WA 98198
5117646 WALGREENS #7730 2700 GRANDVIEW BLVD WAUKESHA WI 53188
5119501 WALGREENS #7882 603 W PINE ST BARABOO WI 53913
5119753 WALMART PHARMACY 10-1394 10600 W LAYTON AVE GREENFIELD WI 53228
5121998 SHOPKO PHARMACY #2617 N2585 PLAZA RD WAUTOMA WI 54982-7706
5122065 OHDE HEALTH MART PHARMACY 628 SECOND STREET CHETEK WI 54728
5123500 RED CLIFF COMM HLTH CTR PHY 36745 AIKEN RD BAYFIELD WI 54814
5127623 WALGREENS #7880 421 S EISENHOWER PKWY RHINELANDER WI 54501
5129007 CVS PHARMACY 8661 N PORT WASHINGTON FOX POINT WI 53217
5129374 WESTFIELDS HOSPITAL 535 HOSPITAL RD NEW RICHMOND WI 54017
5130098 WALGREENS #11253 607 PARK AVE BEAVER DAM WI 53916
5131533 WALGREENS #10758 110 LAKE SHORE DR W ASHLAND WI 54806-1645
5132814 WALGREENS 504 S 17TH AVE WAUSAU WI 54401-5201
5133234 CVS PHARMACY #07261 2631 TOWER AVE SUPERIOR WI 54880-4846
5134197 THEDACARE MEDICAL CENTER WAUPACA 800 RIVERSIDE DR WAUPACA WI 54981-1943
5134200 THEDACARE REGIONAL MEDICAL CENTER 1818 N MEADE ST APPLETON WI 54911-3454
5620198 CVS PHARMACY 3327 ROSECRANS ST SAN DIEGO CA 92110
5621544 CVS PHARMACY 6588 FOOTHILL BLVD TUJUNGA CA 91042
5703029 CVS/PHARMACY #06853 49581 US HIGHWAY 27 DAVENPORT FL 33897-9507
5703269 CVS PHARMACY # 05747 6085 W IRLO BRONSON MEMORIAL HWY KISSIMMEE FL 34747-4512
5712787 ALPHA-OMEGA PHARMACY, LLC 4625 E BAY DR STE 313 CLEARWATER FL 33764-5747
5716305 PUBLIX PHARMACY #1447 4240 53RD AVE E BRADENTON FL 34203-8097
5722740 CVS PHARMACY #10122 5610 OVERSEAS HIGHWAY STOCK ISLAND FL 33040
NETWORK PHARMCY MATCH
RFP - HR1809 Medical Benefits
23 of 23 9:57 AM
Pharmacy
NABPPharmacy Name Pharmacy Address Pharmacy City
Pharmacy
State
Pharmacy
Zip
Included in Proposed
Pharmacy Network (Y/N)Comments
5906257 ASPCARES 1219 BARRANCA DR STE A EL PASO TX 79935-4601
6003139 IMPRIMISRX 780 PRIMOS AVE FOLCROFT PA 19032-2000
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
1 2/22/2018
Ramsey County
Formulary Tier Match
Generic = 1
Preferred Brand = 2
Non-Preferred Brand = 3
Specialty = 4
Preventive (member pays $0) = 5
Excluded from the proposed Formulary (member pays 100%) = 6
• In column D & column E, indicate if the NDA is required to have a Prior Authorization or Step Therapy on your proposed formulary.• Do not delete rows or columns or change the exhibit in such a way that the data provided here is altered
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00173068220 VENTOLIN HFA
16729018317 HYDROCHLOROTHIAZIDE
00781279010 OMEPRAZOLE
60505258008 ATORVASTATIN CALCIUM
16729000517 SIMVASTATIN
60505257908 ATORVASTATIN CALCIUM
65862020299 LOSARTAN POTASSIUM
00054327099 FLUTICASONE PROPIONATE
00378615010 OMEPRAZOLE
65862001305 SERTRALINE HCL
50383070016 FLUTICASONE PROPIONATE
55111012390 ATORVASTATIN CALCIUM
65862020399 LOSARTAN POTASSIUM
55111015810 OMEPRAZOLE
68462039610 OMEPRAZOLE
16729000617 SIMVASTATIN
68180075103 AMLODIPINE BESYLATE
00088221905 LANTUS SOLOSTAR
68180075203 AMLODIPINE BESYLATE
55111012290 ATORVASTATIN CALCIUM
65862001205 SERTRALINE HCL
49884082510 METOPROLOL SUCCINATE ER
00185061010 LISINOPRIL
49884082610 METOPROLOL SUCCINATE ER
00172208380 HYDROCHLOROTHIAZIDE
60505257808 ATORVASTATIN CALCIUM
00185062010 LISINOPRIL
43547035611 LISINOPRIL
68180098003 LISINOPRIL
00781150610 ATENOLOL
60505267108 ATORVASTATIN CALCIUM
60505082901 FLUTICASONE PROPIONATE
• In column C, enter the formulary tier for each NDC listed for your proposed formulary. Values must equal 1-6 as defined below.
Failure to comply with the values listed may result in elimination from consideration. If your formulary has other categories not listed
in 1-6 below, you must provide a key for interpretation.
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
2 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68180098103 LISINOPRIL
00378180510 LEVOTHYROXINE SODIUM
00378521005 AMLODIPINE BESYLATE
00378180310 LEVOTHYROXINE SODIUM
50111043301 TRAZODONE HCL
62037083101 METOPROLOL SUCCINATE ER
57237001405 TAMSULOSIN HCL
00002879959 HUMALOG KWIKPEN
68180051703 LISINOPRIL
13668001005 CITALOPRAM HYDROBROMIDE
00378180910 LEVOTHYROXINE SODIUM
65862020199 LOSARTAN POTASSIUM
00173069600 ADVAIR DISKUS
00603616028 TRAZODONE HCL
53746022010 METFORMIN HCL
67877015905 METFORMIN HCL ER
68180046403 SIMVASTATIN
65162010250 GABAPENTIN
00378020810 FUROSEMIDE
00591217205 HYDROCODONE/ACETAMINOPHEN
49884082710 METOPROLOL SUCCINATE ER
00093310905 AMOXICILLIN
68180047903 SIMVASTATIN
69452015120 VITAMIN D
53746021810 METFORMIN HCL
51672403203 WARFARIN SODIUM
68382013201 TAMSULOSIN HCL
00406012301 HYDROCODONE/ACETAMINOPHEN
00597014030 TRADJENTA
00781282201 FLUOXETINE HCL
55111012190 ATORVASTATIN CALCIUM
00527134210 LEVOTHYROXINE SODIUM
68180051802 LISINOPRIL/HYDROCHLOROTHI
31722072630 MONTELUKAST SODIUM
68180051303 LISINOPRIL
00597007541 SPIRIVA HANDIHALER
53746021805 METFORMIN HCL
60505265305 TRAZODONE HCL
68180051902 LISINOPRIL/HYDROCHLOROTHI
00378615097 OMEPRAZOLE
00185540010 LISINOPRIL
69097081412 GABAPENTIN
00378180710 LEVOTHYROXINE SODIUM
00591333119 BUPROPION HCL XL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
3 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378001805 METOPROLOL TARTRATE
50111064801 FLUOXETINE HCL
49884072703 DOXYCYCLINE MONOHYDRATE
62037083201 METOPROLOL SUCCINATE ER
00378623201 CITALOPRAM HYDROBROMIDE
53746022005 METFORMIN HCL
50111078751 AZITHROMYCIN
68180052002 LISINOPRIL/HYDROCHLOROTHI
55111012490 ATORVASTATIN CALCIUM
00002751001 HUMALOG
00378520905 AMLODIPINE BESYLATE
00378181110 LEVOTHYROXINE SODIUM
62037099901 POTASSIUM CHLORIDE ER
29300012810 HYDROCHLOROTHIAZIDE
69097012705 AMLODIPINE BESYLATE
00527134310 LEVOTHYROXINE SODIUM
68462024805 RANITIDINE HCL
00378520977 AMLODIPINE BESYLATE
00093738556 VENLAFAXINE HCL ER
62037083001 METOPROLOL SUCCINATE ER
00169406013 VICTOZA
00093075210 ATENOLOL
16714050402 GABAPENTIN
00003089421 ELIQUIS
00527134601 LEVOTHYROXINE SODIUM
16714004211 ALLOPURINOL
00527134510 LEVOTHYROXINE SODIUM
00093735556 FINASTERIDE
00093078710 ATENOLOL
68180047902 SIMVASTATIN
68382002310 ATENOLOL
10370010103 BUPROPION HCL XL
31722071390 PANTOPRAZOLE SODIUM
00591544305 PREDNISONE
57664064888 CHLORTHALIDONE
00378181510 LEVOTHYROXINE SODIUM
16714063301 ALENDRONATE SODIUM
60505258009 ATORVASTATIN CALCIUM
43547035411 LISINOPRIL
57664050658 METOPROLOL TARTRATE
68180051403 LISINOPRIL
54092038701 ADDERALL XR
68180051503 LISINOPRIL
00378395177 ATORVASTATIN CALCIUM
60505257909 ATORVASTATIN CALCIUM
69315011610 FUROSEMIDE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
4 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
60505265401 TRAZODONE HCL
00173069700 ADVAIR DISKUS
68180035309 SERTRALINE HCL
45963014205 BUPROPION HCL XL
43547035311 LISINOPRIL
59762033302 LATANOPROST
13668042990 PANTOPRAZOLE SODIUM
17478062512 LATANOPROST
16714068203 SIMVASTATIN
54092039101 ADDERALL XR
55111015834 OMEPRAZOLE
53746017810 METFORMIN HCL ER
65862019399 FLUOXETINE HCL
33342010215 MONTELUKAST SODIUM
53746017805 METFORMIN HCL ER
00093729605 CARVEDILOL
00054429731 FUROSEMIDE
00093007401 ZOLPIDEM TARTRATE
00430375414 ESTRACE
00378181310 LEVOTHYROXINE SODIUM
00023320503 LUMIGAN
24208046325 LATANOPROST
57237000511 FLUCONAZOLE
16252060144 ALENDRONATE SODIUM
51991077205 LANSOPRAZOLE
00378022201 CHLORTHALIDONE
50458057930 XARELTO
00093314705 CEPHALEXIN
16729016901 ESCITALOPRAM OXALATE
65862006399 METOPROLOL TARTRATE
68180046409 SIMVASTATIN
16714004112 ALLOPURINOL
68382031910 TRAMADOL HCL
50111078766 AZITHROMYCIN
00527134110 LEVOTHYROXINE SODIUM
00116200116 CHLORHEXIDINE GLUCONATE
00603210932 AMLODIPINE BESYLATE
00406055201 OXYCODONE HCL
00093731498 CLOPIDOGREL
00093172101 WARFARIN SODIUM
00591024005 LORAZEPAM
59762015601 ATORVASTATIN CALCIUM
69097084905 ESCITALOPRAM OXALATE
10370074605 GLIPIZIDE ER
51672403201 WARFARIN SODIUM
65862000605 CITALOPRAM HYDROBROMIDE
00527134401 LEVOTHYROXINE SODIUM
29300024310 AMLODIPINE BESYLATE
00228298150 OXYCODONE/ACETAMINOPHEN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
5 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00052027303 NUVARING
69097083512 SERTRALINE HCL
69097012805 AMLODIPINE BESYLATE
16714022502 LOSARTAN POTASSIUM/HYDROC
00378075110 CYCLOBENZAPRINE HCL
00378001401 METHOTREXATE
31722072610 MONTELUKAST SODIUM
60505006501 OMEPRAZOLE
10370010150 BUPROPION HCL XL
00378021610 FUROSEMIDE
69097084805 ESCITALOPRAM OXALATE
65162010150 GABAPENTIN
00781506805 TRIAMTERENE/HYDROCHLOROTH
00781282401 FLUOXETINE HCL
00406051201 OXYCODONE/ACETAMINOPHEN
50742013501 ALLOPURINOL
52544024828 TRINESSA
00093013505 CARVEDILOL
50111043303 TRAZODONE HCL
60505257809 ATORVASTATIN CALCIUM
31722088390 ROSUVASTATIN CALCIUM
50111043401 TRAZODONE HCL
00527134710 LEVOTHYROXINE SODIUM
57664016758 METOPROLOL TARTRATE
50924097110 ACCU-CHEK SOFTCLIX LANCET
00378023110 ATENOLOL
68382002210 ATENOLOL
16729018201 HYDROCHLOROTHIAZIDE
00093715510 SIMVASTATIN
00591024105 LORAZEPAM
49281040165 FLUZONE HIGH-DOSE PF 2017
31722073190 IRBESARTAN
69097012815 AMLODIPINE BESYLATE
63304029601 HYDROXYCHLOROQUINE SULFAT
68180051901 LISINOPRIL/HYDROCHLOROTHI
00378021810 ATENOLOL
13668010401 ISOSORBIDE MONONITRATE ER
68180052001 LISINOPRIL/HYDROCHLOROTHI
10370010203 BUPROPION HCL XL
00603616132 TRAZODONE HCL
65862000899 METFORMIN HCL
00781572005 POTASSIUM CHLORIDE ER
68645051554 AMLODIPINE BESYLATE
65862001005 METFORMIN HCL
00378003210 METOPROLOL TARTRATE
65862050320 AMOXICILLIN/CLAVULANATE P
47781030301 NITROFURANTOIN MONOHYDRAT
00054429931 FUROSEMIDE
60505017009 PRAVASTATIN SODIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
6 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00046087221 PREMARIN
00093738698 VENLAFAXINE HCL ER
59746038210 HYDROCHLOROTHIAZIDE
13107015599 PAROXETINE HCL
68180035209 SERTRALINE HCL
68180051801 LISINOPRIL/HYDROCHLOROTHI
59762015701 ATORVASTATIN CALCIUM
00378623301 CITALOPRAM HYDROBROMIDE
00093715410 SIMVASTATIN
00088222033 LANTUS
00591034705 HYDROCHLOROTHIAZIDE
16729009001 FINASTERIDE
68382075810 METFORMIN HCL
68180012202 CEPHALEXIN
53746010901 HYDROCODONE/ACETAMINOPHEN
68645051054 HYDROCHLOROTHIAZIDE
68382050010 OMEPRAZOLE
65862000505 CITALOPRAM HYDROBROMIDE
00023916330 RESTASIS
00093738598 VENLAFAXINE HCL ER
00378180010 LEVOTHYROXINE SODIUM
00378521077 AMLODIPINE BESYLATE
00781107810 ATENOLOL
00093007301 ZOLPIDEM TARTRATE
60505267109 ATORVASTATIN CALCIUM
68462019005 NAPROXEN
59310020412 QVAR
69315011710 FUROSEMIDE
68382013616 LOSARTAN POTASSIUM
31722088490 ROSUVASTATIN CALCIUM
00173071920 FLOVENT HFA
69097082112 GEMFIBROZIL
00065026025 TRAVATAN Z
16714029904 AMOXICILLIN
57237011490 ALFUZOSIN HCL ER
00378181377 LEVOTHYROXINE SODIUM
16714062201 ZOLPIDEM TARTRATE
52544024728 MONONESSA
00378623101 CITALOPRAM HYDROBROMIDE
61971012005 SULFAMETHOXAZOLE/TRIMETHO
69097022416 ALENDRONATE SODIUM
13668001105 CITALOPRAM HYDROBROMIDE
65862019901 GABAPENTIN
61314054701 LATANOPROST
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
7 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
65162062711 TRAMADOL HCL
64380073706 VITAMIN D
00378001801 METOPROLOL TARTRATE
00093754356 DULOXETINE HCL
50111064803 FLUOXETINE HCL
50458014130 INVOKANA
51525029403 AZELASTINE HYDROCHLORIDE
00023921105 COMBIGAN
00378520805 AMLODIPINE BESYLATE
68382009601 HYDROXYCHLOROQUINE SULFAT
00074433902 HUMIRA PEN
00527134901 LEVOTHYROXINE SODIUM
55111046701 METOPROLOL SUCCINATE ER
57664047758 METOPROLOL TARTRATE
55111046705 METOPROLOL SUCCINATE ER
68180051701 LISINOPRIL
43547036109 LOSARTAN POTASSIUM
16729017001 ESCITALOPRAM OXALATE
00591084410 GLIPIZIDE ER
31722088530 ROSUVASTATIN CALCIUM
53489014310 SPIRONOLACTONE
68645051654 AMLODIPINE BESYLATE
65862019405 FLUOXETINE HCL
00093726710 METFORMIN HCL ER
16714047801 AMOXICILLIN/CLAVULANATE P
00781181810 FUROSEMIDE
00093738456 VENLAFAXINE HCL ER
60505025302 CLOPIDOGREL
59746000103 METHYLPREDNISOLONE DOSE P
00378395277 ATORVASTATIN CALCIUM
65862005299 SIMVASTATIN
68382009810 PAROXETINE HCL
16714048101 TRAMADOL HCL
00093720298 PRAVASTATIN SODIUM
00093729505 CARVEDILOL
00591578201 ATENOLOL/CHLORTHALIDONE
00555088602 ESTRADIOL
00591271701 METHYLPHENIDATE HCL ER
16729003510 ANASTROZOLE
50383023310 DORZOLAMIDE HCL/TIMOLOL M
68180035302 SERTRALINE HCL
00378334053 XULANE
00173069500 ADVAIR DISKUS
43386009019 GAVILYTE-G
13668011890 LOSARTAN POTASSIUM/HYDROC
68180075009 AMLODIPINE BESYLATE
65162022621 YUVAFEM
16729018417 HYDROCHLOROTHIAZIDE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
8 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00071101668 LYRICA
49884022811 EZETIMIBE
45802046564 KETOCONAZOLE
65862005390 SIMVASTATIN
00378181177 LEVOTHYROXINE SODIUM
43547036209 LOSARTAN POTASSIUM
00071101568 LYRICA
47781047013 OSELTAMIVIR PHOSPHATE
68180065208 DOXYCYCLINE MONOHYDRATE
54092038901 ADDERALL XR
00093416173 AMOXICILLIN
47335089413 CLOPIDOGREL
00378034505 DIAZEPAM
68180051202 LISINOPRIL
10702001801 OXYCODONE HCL
51248015001 VESICARE
61314063705 PREDNISOLONE ACETATE
00378018105 ALLOPURINOL
00378395377 ATORVASTATIN CALCIUM
00781550301 METFORMIN HCL ER
65162003311 ACETAMINOPHEN/CODEINE PHO
16714035903 FALMINA
43547035150 LISINOPRIL
43547035211 LISINOPRIL
00093738656 VENLAFAXINE HCL ER
65702071110 ACCU-CHEK GUIDE
65862042005 SULFAMETHOXAZOLE/TRIMETHO
00555097202 AMPHETAMINE/DEXTROAMPHETA
62037083010 METOPROLOL SUCCINATE ER
65862001105 SERTRALINE HCL
29300013510 CLONIDINE HCL
16729021816 CLOPIDOGREL
70461020101 FLUCELVAX QUADRIVALENT 20
00603389021 HYDROCODONE/ACETAMINOPHEN
00603411021 ISOSORBIDE MONONITRATE ER
00093001298 PANTOPRAZOLE SODIUM
00173072020 FLOVENT HFA
16714068303 SIMVASTATIN
50742013605 ALLOPURINOL
69097083412 SERTRALINE HCL
45963055550 GABAPENTIN
00555901658 SPRINTEC 28
00781100805 TRIAMTERENE/HYDROCHLOROTH
00143962125 CYANOCOBALAMIN
00228299650 TAMSULOSIN HCL
00781112305 TRIAMTERENE/HYDROCHLOROTH
00378191010 CLONAZEPAM
00378145201 ESTRADIOL
00781196610 FUROSEMIDE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
9 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378180777 LEVOTHYROXINE SODIUM
51862002806 LUTERA
65862000805 METFORMIN HCL
00555904558 AVIANE
00781282301 FLUOXETINE HCL
13668011590 LOSARTAN POTASSIUM
00093720198 PRAVASTATIN SODIUM
58406044504 ENBREL SURECLICK
42806005705 AMLODIPINE BESYLATE
00173085910 BREO ELLIPTA
43547028910 BUPROPION HCL ER
57237001999 DULOXETINE HCL
00591084501 GLIPIZIDE ER
00378182377 LEVOTHYROXINE SODIUM
61314022705 TIMOLOL MALEATE
00093083201 CLONAZEPAM
00527163801 LEVOTHYROXINE SODIUM
00093551798 SILDENAFIL
13107007001 AMPHETAMINE/DEXTROAMPHETA
65162083366 DICLOFENAC SODIUM
00093735156 LANSOPRAZOLE
23155010210 METFORMIN HCL
59746017506 PREDNISONE
53746025310 RANITIDINE HCL
00228280350 SPIRONOLACTONE
55111029209 SUMATRIPTAN SUCCINATE
00781207410 TRIAMTERENE/HYDROCHLOROTH
00228202996 ALPRAZOLAM
00781282210 FLUOXETINE HCL
00781518492 LEVOTHYROXINE SODIUM
69097087512 BUPROPION HCL XL
00781518592 LEVOTHYROXINE SODIUM
16714022604 LOSARTAN POTASSIUM/HYDROC
00591544210 PREDNISONE
00093735201 CALCITRIOL
00093754456 DULOXETINE HCL
00555089902 ESTRADIOL
58160090752 FLUARIX QUADRIVALENT 2017
00781185220 AMOXICILLIN/CLAVULANATE P
62037059890 CARTIA XT
69097081312 GABAPENTIN
69238110305 IBUPROFEN
68382000801 LAMOTRIGINE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
10 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378180577 LEVOTHYROXINE SODIUM
51672402901 WARFARIN SODIUM
43547037509 IRBESARTAN
00186037020 SYMBICORT
00093005805 TRAMADOL HCL
69097015305 VALACYCLOVIR HCL
00378013701 ALLOPURINOL
00115552202 FENOFIBRATE
50111064701 FLUOXETINE HCL
00591090030 GLIPIZIDE ER
00069046956 CHANTIX
00378081005 HYDROCHLOROTHIAZIDE
68180085413 LEVONORGESTREL/ETHINYL ES
68382000105 PAROXETINE HCL
00781261305 AMOXICILLIN
00093005401 BUSPIRONE HCL
49884022809 EZETIMIBE
13107003134 MIRTAZAPINE
51991074810 DULOXETINE HCL
00071101468 LYRICA
29300022019 MONTELUKAST SODIUM
64980051405 TIMOLOL MALEATE
50924045001 ACCU-CHEK MULTICLIX LANCE
00781150710 ATENOLOL
69238110205 IBUPROFEN
00527135001 LEVOTHYROXINE SODIUM
00054001825 PREDNISONE
00603316232 FOLIC ACID
00378004710 METOPROLOL TARTRATE
68382003416 VENLAFAXINE HCL ER
69097087812 BUPROPION HCL SR
59746017710 CYCLOBENZAPRINE HCL
16714040604 LARIN FE 1/20
00781518192 LEVOTHYROXINE SODIUM
00603499028 OXYCODONE HCL
00591544301 PREDNISONE
68382013716 LOSARTAN POTASSIUM
68382060010 POTASSIUM CHLORIDE ER
00591505210 PREDNISONE
10370010250 BUPROPION HCL XL
69097087612 BUPROPION HCL XL
00555057202 METHOTREXATE
59746017306 PREDNISONE
31722077705 ACYCLOVIR
00093716601 CELECOXIB
49884093547 DICLOFENAC SODIUM
31722077690 SILDENAFIL
65862007701 CIPROFLOXACIN HCL
64980028101 GLIPIZIDE ER
69097012605 AMLODIPINE BESYLATE
59762306001 AZITHROMYCIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
11 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
49502010202 EPINEPHRINE
00781145310 GLIPIZIDE
60758011905 PREDNISOLONE ACETATE
53489032805 SPIRONOLACTONE
51248015101 VESICARE
00378075710 ATENOLOL
60505083305 AZELASTINE HCL
00781518392 LEVOTHYROXINE SODIUM
62756014202 METFORMIN HCL ER
51991081701 PROPRANOLOL HCL ER
68180022006 RABEPRAZOLE SODIUM
68180047803 SIMVASTATIN
55111018015 TIZANIDINE HCL
61958070101 TRUVADA
31722073030 IRBESARTAN
57664039753 METFORMIN HCL
33342005610 PIOGLITAZONE HCL
00781150701 ATENOLOL
00781569092 EZETIMIBE
00085461001 DULERA
00378464226 ESTRADIOL
68462039710 OMEPRAZOLE
00046110081 PREMARIN
00186091612 PULMICORT FLEXHALER
00185014405 AMIODARONE HCL
16729017101 AMITRIPTYLINE HCL
00378100501 AZATHIOPRINE
00310653004 BYDUREON PEN
65862019801 GABAPENTIN
55111046801 METOPROLOL SUCCINATE ER
00046110281 PREMARIN
65862001705 AMOXICILLIN
68180013601 ESCITALOPRAM OXALATE
16714046404 JULEBER
68180021509 LOSARTAN POTASSIUM/HYDROC
00093720656 MIRTAZAPINE
50458057990 XARELTO
00378395077 ATORVASTATIN CALCIUM
62037099905 POTASSIUM CHLORIDE ER
60505016907 PRAVASTATIN SODIUM
00003089321 ELIQUIS
68180088213 ENSKYCE
00591024101 LORAZEPAM
68645053959 METFORMIN HCL
00591521505 METRONIDAZOLE
65162019050 NAPROXEN
55111029236 SUMATRIPTAN SUCCINATE
00527133001 BACLOFEN
50111033401 METRONIDAZOLE
62175027137 OXYBUTYNIN CHLORIDE ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
12 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00143973805 PREDNISONE
59746017206 PREDNISONE
59762015801 ATORVASTATIN CALCIUM
00378181577 LEVOTHYROXINE SODIUM
62037083110 METOPROLOL SUCCINATE ER
51862027906 MICROGESTIN 1.5/30
68462030529 NORETHINDRONE
57237017090 ROSUVASTATIN CALCIUM
00597010061 SPIRIVA RESPIMAT
57237001401 TAMSULOSIN HCL
00781112301 TRIAMTERENE/HYDROCHLOROTH
66993016502 COLCHICINE
65862019299 FLUOXETINE HCL
67877022305 GABAPENTIN
57237007710 ONDANSETRON ODT
60505008000 SOTALOL HCL
45802006405 TRIAMCINOLONE ACETONIDE
00713525601 CLINDAMYCIN HCL
00228212750 CLONIDINE HCL
00115981101 DIGOXIN
68682099398 DILTIAZEM HCL ER
59762054201 GLIPIZIDE XL
10702001150 HYDROXYZINE HCL
52544096691 QUASENSE
62037059790 CARTIA XT
16714069211 FLUCONAZOLE
00378182310 LEVOTHYROXINE SODIUM
68180050203 MELOXICAM
68382076010 METFORMIN HCL
33342005510 PIOGLITAZONE HCL
00555902058 PORTIA-28
53746051401 SPIRONOLACTONE
00093716456 TOLTERODINE TARTRATE ER
42806005605 AMLODIPINE BESYLATE
68382060001 POTASSIUM CHLORIDE ER
59310021012 QNASL
68462024901 RANITIDINE HCL
43547027010 ROPINIROLE HCL
00093416178 AMOXICILLIN
00051846233 ANDROGEL PUMP
00168020360 CLINDAMYCIN PHOSPHATE
59746033090 DONEPEZIL HCL
66993005702 HYDROXYCHLOROQUINE SULFAT
70700026330 LANSOPRAZOLE
00185063001 LISINOPRIL
00469260230 MYRBETRIQ
62037071001 POTASSIUM CHLORIDE CR
16714062202 ZOLPIDEM TARTRATE
00173088210 BREO ELLIPTA
16714046901 CLONAZEPAM
51672400102 NORTRIPTYLINE HCL
68645052354 SERTRALINE HCL
16729000417 SIMVASTATIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
13 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
64380071206 BENZONATATE
23155011801 CALCITRIOL
42043014105 CEPHALEXIN
00093724806 LAMOTRIGINE
00185062001 LISINOPRIL
00378342201 NITROFURANTOIN MONOHYDRAT
00093520701 OXYBUTYNIN CHLORIDE ER
61314062810 POLYMYXIN B SULFATE/TRIME
16714061105 SERTRALINE HCL
16729021716 SERTRALINE HCL
65862014836 SUMATRIPTAN SUCCINATE
00378340493 TOLTERODINE TARTRATE ER
00169406012 VICTOZA
54458088116 ATORVASTATIN CALCIUM
00193731221 BAYER CONTOUR NEXT BLOOD
57237001899 DULOXETINE HCL
49884072401 HYDROXYUREA
55111068305 IBUPROFEN
54458093316 SIMVASTATIN
43547036009 LOSARTAN POTASSIUM
68382013516 LOSARTAN POTASSIUM
51862000706 MICROGESTIN 1/20
68382053701 POTASSIUM CITRATE ER
50458057830 XARELTO
00093100301 BUSPIRONE HCL
69097015907 MELOXICAM
65162062750 TRAMADOL HCL
16729017217 AMITRIPTYLINE HCL
00603002632 ASPIRIN EC LOW DOSE
00378115005 BUSPIRONE HCL
00597002402 COMBIVENT RESPIMAT
31722052590 FINASTERIDE
00169643810 LEVEMIR FLEXTOUCH
68645041154 LOSARTAN POTASSIUM
54458093210 SIMVASTATIN
00093106101 SOTALOL HCL
52544008728 TRINESSA LO
00904615760 VITAMIN D
51672403001 WARFARIN SODIUM
00555097302 AMPHETAMINE/DEXTROAMPHETA
66993066430 DULOXETINE HCL
17478007035 ERYTHROMYCIN
00378145401 ESTRADIOL
00781145210 GLIPIZIDE
33342004907 IRBESARTAN
00591271801 METHYLPHENIDATE HCL ER
43598043611 NITROGLYCERIN
00093715310 SIMVASTATIN
68382014005 TOPIRAMATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
14 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00115168134 ALENDRONATE SODIUM
66685100100 AMOXICILLIN/CLAVULANATE P
00093005301 BUSPIRONE HCL
00054418425 DEXAMETHASONE
45802013275 FENOFIBRATE
00002751659 HUMALOG
53746046505 IBUPROFEN
50458014030 INVOKANA
00378181710 LEVOTHYROXINE SODIUM
00093204956 TOLTERODINE TARTRATE ER
67877019910 AMLODIPINE BESYLATE
16714065202 CIPROFLOXACIN HCL
60505009500 DOXAZOSIN
00591046005 GLIPIZIDE
68645054659 METFORMIN HCL
68180088613 NIKKI
57664022388 OXYCODONE HCL
00054472831 PREDNISONE
54458093310 SIMVASTATIN
00603576321 SPIRONOLACTONE
50111043302 TRAZODONE HCL
00904582460 VITAMIN D3
68382079101 ACYCLOVIR
00781107705 ALPRAZOLAM
00085134107 ASMANEX TWISTHALER 30 MET
64980028001 GLIPIZIDE ER
00054004641 IPRATROPIUM BROMIDE
68382065005 ISOSORBIDE MONONITRATE ER
65862020390 LOSARTAN POTASSIUM
62037083301 METOPROLOL SUCCINATE ER
16714068503 SIMVASTATIN
00591046105 GLIPIZIDE
00574041202 POLYETHYLENE GLYCOL 3350
52544095428 RECLIPSEN
31722088290 ROSUVASTATIN CALCIUM
68180046509 SIMVASTATIN
65862000705 CITALOPRAM HYDROBROMIDE
69315012710 FOLIC ACID
68180021709 LOSARTAN POTASSIUM/HYDROC
00093742698 MONTELUKAST SODIUM
59762330403 NITROGLYCERIN
60432053716 NYSTATIN
13107015699 PAROXETINE HCL
53746051101 SPIRONOLACTONE
00781506705 TRIAMTERENE/HYDROCHLOROTH
00065853302 CIPRODEX
33342002810 DONEPEZIL HCL
69097081212 GABAPENTIN
00378207510 LISINOPRIL
55111046601 METOPROLOL SUCCINATE ER
55111046805 METOPROLOL SUCCINATE ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
15 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
65862059805 TAMSULOSIN HCL
68382013805 TOPIRAMATE
59762015501 ATORVASTATIN CALCIUM
00378191210 CLONAZEPAM
69097084615 CYCLOBENZAPRINE HCL
43547027611 DONEPEZIL HCL
43547022215 LEVETIRACETAM
00781565615 LORYNA
00071101368 LYRICA
00591588301 METHYLPHENIDATE HCL
13668048450 MINOCYCLINE HCL
00378351501 MIRTAZAPINE
59310020212 QVAR
53746025402 RANITIDINE HCL
16714068403 SIMVASTATIN
00228267311 SPIRONOLACTONE
69097012715 AMLODIPINE BESYLATE
69097083805 AMLODIPINE BESYLATE
60505001606 DILT-XR
00173071820 FLOVENT HFA
00002879759 HUMALOG MIX 75/25 KWIKPEN
00781523864 ONDANSETRON ODT
57237004105 PENICILLIN V POTASSIUM
68382039801 POTASSIUM CHLORIDE ER
00228267211 SPIRONOLACTONE
00093171401 WARFARIN SODIUM
00173071720 ADVAIR HFA
76204020025 ALBUTEROL SULFATE
00378116591 BUSPIRONE HCL
55111012701 CIPROFLOXACIN HCL
16729000201 GLIMEPIRIDE
51862009706 LEVORA 0.15/30-28
68645055354 LISINOPRIL
13668011690 LOSARTAN POTASSIUM/HYDROC
51862056406 LOW-OGESTREL
00228202796 ALPRAZOLAM
00186077760 BRILINTA
43547029010 BUPROPION HCL ER
62559038101 FLECAINIDE ACETATE
68645049254 PANTOPRAZOLE SODIUM
00074706890 SYNTHROID
00555901858 TRI-SPRINTEC
13668000805 ZOLPIDEM TARTRATE
00487950103 ALBUTEROL SULFATE
00093226401 AMOXICILLIN
65862001501 AMOXICILLIN
00093520006 BUSPIRONE HCL
43547027511 DONEPEZIL HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
16 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00781405815 ESTARYLLA
49281062715 FLUZONE QUADRIVALENT 2017
00591024110 LORAZEPAM
68180046903 LOVASTATIN
53746017901 METFORMIN HCL ER
45802011222 MUPIROCIN
62332003231 ROPINIROLE HCL
57237017190 ROSUVASTATIN CALCIUM
00228348211 ZOLPIDEM TARTRATE ER
00173086910 ANORO ELLIPTA
00228253910 CARBIDOPA/LEVODOPA
65862037505 ESCITALOPRAM OXALATE
43598030390 FINASTERIDE
00597014860 JENTADUETO
42794001802 LIOTHYRONINE SODIUM
51224000760 METFORMIN HCL ER
55111046901 METOPROLOL SUCCINATE ER
65162004710 OXYCODONE HCL
68462019605 PRAVASTATIN SODIUM
68180035109 SERTRALINE HCL
00378401001 TEMAZEPAM
16714062101 ZOLPIDEM TARTRATE
50924098850 ACCU-CHEK COMPACT PLUS
65162053610 BENZONATATE
00115681108 BUPROPION HCL XL
23155017801 ISOSORBIDE MONONITRATE ER
00781518292 LEVOTHYROXINE SODIUM
51862029206 MICROGESTIN FE 1.5/30
59417010710 VYVANSE
00185014460 AMIODARONE HCL
00555904358 APRI
68382000301 AZATHIOPRINE
16729013716 CLONAZEPAM
65862035790 CLOPIDOGREL
13668040990 LOSARTAN POTASSIUM
00603537121 PRIMIDONE
69543037410 PROGESTERONE
53746027205 SULFAMETHOXAZOLE/TRIMETHO
00378427693 VALACYCLOVIR HCL
65862044830 VALACYCLOVIR HCL
65862052830 VENLAFAXINE HCL ER
00378827052 ALBUTEROL SULFATE
67877019805 AMLODIPINE BESYLATE
00536100836 ASPIRIN
10370074601 GLIPIZIDE ER
59762054101 GLIPIZIDE XL
00002831501 HUMULIN N
00591024001 LORAZEPAM
65862020190 LOSARTAN POTASSIUM
51672131200 MUPIROCIN
68462056529 NORGESTIMATE/ETHINYL ESTR
68382009905 PAROXETINE HCL
00378110101 PRAZOSIN HCL
68180047802 SIMVASTATIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
17 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00093015010 ACETAMINOPHEN/CODEINE
00143988701 AMOXICILLIN
68645049554 ATORVASTATIN CALCIUM
00517003125 CYANOCOBALAMIN
69315011601 FUROSEMIDE
00172208980 HYDROCHLOROTHIAZIDE
31722072690 MONTELUKAST SODIUM
00574200815 NYSTOP
10702005601 OXYCODONE HCL
00023530105 RESTASIS MULTIDOSE
55111017915 TIZANIDINE HCL
61958040101 VIREAD
61314014405 BRIMONIDINE TARTRATE
00185013001 BUMETANIDE
69097081307 GABAPENTIN
00781518692 LEVOTHYROXINE SODIUM
13668011390 LOSARTAN POTASSIUM
68462033090 PRAMIPEXOLE DIHYDROCHLORI
00093077198 PRAVASTATIN SODIUM
00074706990 SYNTHROID
17478028811 TIMOLOL MALEATE
00173071620 ADVAIR HFA
53746010905 HYDROCODONE/ACETAMINOPHEN
00406324301 HYDROMORPHONE HCL
00591024010 LORAZEPAM
55111046605 METOPROLOL SUCCINATE ER
51862001206 MICROGESTIN FE
00469260130 MYRBETRIQ
42858000101 OXYCODONE HCL
65862056090 PANTOPRAZOLE SODIUM
00093221005 SUCRALFATE
00024586903 TOUJEO SOLOSTAR
16714069701 VALACYCLOVIR HCL
00185111160 BUPROPION HCL SR
16714065102 CIPROFLOXACIN HCL
00093731456 CLOPIDOGREL
00172392660 DIAZEPAM
16729041401 DOXAZOSIN MESYLATE
61442012101 FAMOTIDINE
00093067005 GEMFIBROZIL
00093725501 GLIMEPIRIDE
00093046301 LAMOTRIGINE
13107015799 PAROXETINE HCL
00093117410 PENICILLIN V POTASSIUM
69452014820 PROGESTERONE
51862054506 SRONYX
51862003603 ZARAH
00603254421 BUTALBITAL/ACETAMINOPHEN/
68180013501 ESCITALOPRAM OXALATE
65862019301 FLUOXETINE HCL
00591352530 LIDOCAINE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
18 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
65862020290 LOSARTAN POTASSIUM
16714022402 LOSARTAN POTASSIUM/HYDROC
00781571001 POTASSIUM CHLORIDE ER
49281040010 ADACEL
00023932105 ALPHAGAN P
00603240628 BACLOFEN
69097082307 CITALOPRAM HYDROBROMIDE
69238115403 EZETIMIBE
16729000301 GLIMEPIRIDE
10370074505 GLIPIZIDE ER
00115167001 HYDROXYZINE PAMOATE
00054004544 IPRATROPIUM BROMIDE
61703035038 METHOTREXATE SODIUM
65862021150 MINOCYCLINE HCL
55111072510 MONTELUKAST SODIUM
60505450309 ROSUVASTATIN CALCIUM
51672128202 TRIAMCINOLONE ACETONIDE
60505265705 TRIAMTERENE/HYDROCHLOROTH
00781406015 TRI-ESTARYLLA
00378520877 AMLODIPINE BESYLATE
61958200201 DESCOVY
00527132401 DIGOX
00378312501 DOXEPIN HCL
00172572860 FAMOTIDINE
67877022310 GABAPENTIN
00185067401 HYDROXYZINE PAMOATE
54092047612 LIALDA
00591271501 METHYLPHENIDATE HCL ER
00054001725 PREDNISONE
00115166001 PROPRANOLOL HCL
16729014501 QUETIAPINE FUMARATE
68180035202 SERTRALINE HCL
00093221001 SUCRALFATE
53489014601 SULFAMETHOXAZOLE/TRIMETHO
00074662490 SYNTHROID
00093171501 WARFARIN SODIUM
76204020060 ALBUTEROL SULFATE
00378623205 CITALOPRAM HYDROBROMIDE
49884051410 DIGOXIN
00093444305 GABAPENTIN
67877042805 GABAPENTIN
00781323434 GLATOPA
68645055254 LISINOPRIL
54458099110 LISINOPRIL/HYDROCHLOROTHI
00406051205 OXYCODONE/ACETAMINOPHEN
00065027225 PATADAY
61314063710 PREDNISOLONE ACETATE
16729021616 SERTRALINE HCL
00074706819 SYNTHROID
60505265605 TRIAMTERENE/HYDROCHLOROTH
31722070430 VALACYCLOVIR HCL
00603210928 AMLODIPINE BESYLATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
19 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
43547027609 DONEPEZIL HCL
51991074690 DULOXETINE HCL
65162010350 GABAPENTIN
00603390021 HYDROCORTISONE
54458099610 LISINOPRIL
62037083210 METOPROLOL SUCCINATE ER
00406117003 NALTREXONE HCL
59011041010 OXYCONTIN
00093006456 RABEPRAZOLE SODIUM
69097085902 TERBINAFINE HCL
50111044101 TRAZODONE HCL
65862044930 VALACYCLOVIR HCL
00378343393 ARMODAFINIL
43547028810 BUPROPION HCL ER
68682099798 DILTIAZEM HCL ER
00555088702 ESTRADIOL
00406012401 HYDROCODONE/ACETAMINOPHEN
53746046605 IBUPROFEN
00185064010 LISINOPRIL
69315090405 LORAZEPAM
23155010410 METFORMIN HCL
31722053401 METHOCARBAMOL
51991081901 PROPRANOLOL HCL ER
00074659490 SYNTHROID
51672402701 WARFARIN SODIUM
51672402903 WARFARIN SODIUM
55111072910 ALLOPURINOL
00065027510 AZOPT
52817019100 CYCLOBENZAPRINE HCL
70461012002 FLUVIRIN 2017-2018
53746017801 METFORMIN HCL ER
00603459315 METHYLPREDNISOLONE DOSE P
13107000130 MIRTAZAPINE
51862001501 NORTRIPTYLINE HCL
68462033290 PRAMIPEXOLE DIHYDROCHLORI
00574082001 TESTOSTERONE CYPIONATE
45802005505 TRIAMCINOLONE ACETONIDE
67253090050 ALPRAZOLAM
00781148610 AMITRIPTYLINE HCL
00904404073 ASPIRIN
16729013616 CLONAZEPAM
65862035705 CLOPIDOGREL
70069000510 CYANOCOBALAMIN
65862059505 DIVALPROEX SODIUM ER
24208048610 DORZOLAMIDE HCL/TIMOLOL M
16729021301 DOXAZOSIN
00168008031 HYDROCORTISONE
00555906458 KELNOR 1/35
00378181910 LEVOTHYROXINE SODIUM
68180051601 LISINOPRIL
54092019112 PENTASA
00173052100 SEREVENT DISKUS
69097012412 TOPIRAMATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
20 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00168000480 TRIAMCINOLONE ACETONIDE
00002143480 TRULICITY
65649030302 XIFAXAN
69097083815 AMLODIPINE BESYLATE
50111078810 AZITHROMYCIN
00069047103 CHANTIX STARTING MONTH PA
55111012601 CIPROFLOXACIN HCL
51991074710 DULOXETINE HCL
50419082502 FINACEA
00054001125 FLECAINIDE ACETATE
00487020103 IPRATROPIUM BROMIDE/ALBUT
00093724706 LAMOTRIGINE
00781502207 METHYLPREDNISOLONE DOSE P
68462010530 ONDANSETRON HCL
60505016809 PRAVASTATIN SODIUM
00046110511 PREMPRO
00074518290 SYNTHROID
31722070530 VALACYCLOVIR HCL
00591379730 ALBUTEROL SULFATE
00781106105 ALPRAZOLAM
00093075305 ATENOLOL
00591578301 ATENOLOL/CHLORTHALIDONE
00093714656 AZITHROMYCIN
69097042107 CELECOXIB
64980030301 CHLORTHALIDONE
31722072990 IRBESARTAN
68180011302 LEVETIRACETAM
00378180977 LEVOTHYROXINE SODIUM
00781519192 LEVOTHYROXINE SODIUM
54458099710 LISINOPRIL
60505024701 MIRTAZAPINE
69238158306 NORLYDA
51862001601 NORTRIPTYLINE HCL
50111045602 OXYBUTYNIN CHLORIDE
68462019790 PRAVASTATIN SODIUM
00603533521 PREDNISONE
16729000515 SIMVASTATIN
60505265501 TRAZODONE HCL
51672403101 WARFARIN SODIUM
51672403401 WARFARIN SODIUM
16714062102 ZOLPIDEM TARTRATE
68382012305 AMLODIPINE BESYLATE
68645048154 ATORVASTATIN CALCIUM
68180086613 BLISOVI FE 1.5/30
68180086513 BLISOVI FE 1/20
00591354105 BUPROPION HCL SR
00093005105 CARVEDILOL
47781020404 ESTRADIOL
42858030101 HYDROMORPHONE HCL
52544089228 JOLIVETTE
31722053712 LEVETIRACETAM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
21 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378180377 LEVOTHYROXINE SODIUM
00378207310 LISINOPRIL
47335032213 MEMANTINE HCL
00904634060 METOPROLOL TARTRATE
68682045570 METRONIDAZOLE VAGINAL
68462018022 MUPIROCIN
17478071310 OFLOXACIN
00378773293 ONDANSETRON ODT
68462033190 PRAMIPEXOLE DIHYDROCHLORI
16252057350 RAMIPRIL
54838055080 RANITIDINE HCL
16714061205 SERTRALINE HCL
65862005190 SIMVASTATIN
17478028810 TIMOLOL MALEATE
49702022813 TIVICAY
68382013905 TOPIRAMATE
64764091830 ULORIC
00093738498 VENLAFAXINE HCL ER
00456114030 VIIBRYD
59417010610 VYVANSE
29300015519 ALFUZOSIN HCL ER
68382002401 ATENOLOL
15584010101 ATRIPLA
00002446430 CIALIS
00713317101 CLINDAMYCIN HCL
00093083301 CLONAZEPAM
68180036309 FENOFIBRATE
00185067405 HYDROXYZINE PAMOATE
00168009930 KETOCONAZOLE
00781518792 LEVOTHYROXINE SODIUM
49884082601 METOPROLOL SUCCINATE ER
68462010630 ONDANSETRON HCL
00591505201 PREDNISONE
33342009472 RIZATRIPTAN BENZOATE ODT
00781207401 TRIAMTERENE/HYDROCHLOROTH
00378341201 BUPROPION HCL SR
00378116580 BUSPIRONE HCL
00378117591 BUSPIRONE HCL
60505082306 CALCITONIN-SALMON
68180071160 CEFDINIR
69097082312 CITALOPRAM HYDROBROMIDE
63304069301 CLINDAMYCIN HCL
59762374301 CLINDAMYCIN PHOSPHATE
00591248279 DORZOLAMIDE HCL/TIMOLOL M
00093754206 DULOXETINE HCL
00002512330 EFFIENT
69315011701 FUROSEMIDE
55111068405 IBUPROFEN
68645040754 LOSARTAN POTASSIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
22 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
49884082801 METOPROLOL SUCCINATE ER
60758011910 PREDNISOLONE ACETATE
00074929690 SYNTHROID
00378027493 TAMOXIFEN CITRATE
00378135501 TRIAMTERENE/HYDROCHLOROTH
00781148710 AMITRIPTYLINE HCL
00185041001 BUPROPION HCL SR
58914017014 CARAFATE
13668001001 CITALOPRAM HYDROBROMIDE
00591293201 CLINDAMYCIN HCL
16571020150 DICLOFENAC SODIUM DR
60505299603 DULOXETINE HCL
60432026415 FLUTICASONE PROPIONATE
16714050302 GABAPENTIN
60505014101 GLIPIZIDE
00781558436 INTROVALE
17478020910 KETOROLAC TROMETHAMINE
00378180077 LEVOTHYROXINE SODIUM
68180051301 LISINOPRIL
68382005101 MELOXICAM
00378718505 METFORMIN HCL
64980026001 METHIMAZOLE
13107000334 MIRTAZAPINE
62175061746 PANTOPRAZOLE SODIUM
24208031510 POLYMYXIN B SULFATE/TRIME
68462033390 PRAMIPEXOLE DIHYDROCHLORI
00527163210 TRIAMTERENE/HYDROCHLOROTH
00378632001 VERAPAMIL HCL ER
57237012401 WARFARIN SODIUM
00406048401 ACETAMINOPHEN/CODEINE
16714004107 ALLOPURINOL
00228291809 DILTIAZEM HCL ER
24208091055 ERYTHROMYCIN
60758088005 FLUOROMETHOLONE
43547038950 GABAPENTIN
10370074501 GLIPIZIDE ER
57237000201 HYDROCHLOROTHIAZIDE
24208039915 IPRATROPIUM BROMIDE
65862047090 LOSARTAN POTASSIUM/HYDROC
62756014301 METFORMIN HCL ER
31722053301 METHOCARBAMOL
65862020901 MINOCYCLINE HCL
00603763417 ORSYTHIA
00054001925 PREDNISONE
69543037510 PROGESTERONE
16714045202 QUETIAPINE FUMARATE
00781205305 TERAZOSIN HCL
69097012212 TOPIRAMATE
60505004206 ACYCLOVIR
13107007401 AMPHETAMINE/DEXTROAMPHETA
00781598701 CARBAMAZEPINE ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
23 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
16714046902 CLONAZEPAM
59746032990 DONEPEZIL HCL
00093775698 FENOFIBRATE
00378034201 GLIPIZIDE ER
59762054202 GLIPIZIDE XL
68180041209 IRBESARTAN
55111039990 LANSOPRAZOLE
65862046990 LOSARTAN POTASSIUM/HYDROC
68645019059 METOPROLOL TARTRATE
00713063337 METRONIDAZOLE
00603781878 NYSTATIN
00023916360 RESTASIS
00591247330 TAMOXIFEN CITRATE
24208029005 TOBRAMYCIN SULFATE
00597014090 TRADJENTA
00781557515 VIENVA
59417010310 VYVANSE
00603210925 AMLODIPINE BESYLATE
13107007301 AMPHETAMINE/DEXTROAMPHETA
62175089043 ATORVASTATIN CALCIUM
65162005350 CITALOPRAM HYDROBROMIDE
65162005450 CITALOPRAM HYDROBROMIDE
47781010830 EXEMESTANE
16729009015 FINASTERIDE
61314012605 KETOROLAC TROMETHAMINE
16714037404 LAMOTRIGINE
16714040504 LARIN FE 1.5/30
13668011790 LOSARTAN POTASSIUM/HYDROC
00591271601 METHYLPHENIDATE HCL ER
49884082701 METOPROLOL SUCCINATE ER
16714036004 MONO-LINYAH
60505317007 OMEGA-3-ACID ETHYL ESTERS
43547035009 PAROXETINE HCL
60505016909 PRAVASTATIN SODIUM
00054001729 PREDNISONE
00603576421 SPIRONOLACTONE
68382013814 TOPIRAMATE
68382014014 TOPIRAMATE
68382003606 VENLAFAXINE HCL ER
52544098231 VESTURA
65162022623 YUVAFEM
67253090150 ALPRAZOLAM
67877010505 BENZONATATE
49884087201 FLUOXETINE HCL
65162036111 FOLIC ACID
31722052001 HYDRALAZINE HCL
16729018401 HYDROCHLOROTHIAZIDE
00472033730 HYDROCORTISONE
00555032302 HYDROXYZINE PAMOATE
00555902658 JUNEL FE 1/20
00378181777 LEVOTHYROXINE SODIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
24 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00781518892 LEVOTHYROXINE SODIUM
69315090505 LORAZEPAM
55111059660 MEMANTINE HCL
66993096045 METRONIDAZOLE
17478076610 PROGESTERONE
68180044701 QUETIAPINE FUMARATE
16714061305 SERTRALINE HCL
68645052254 SERTRALINE HCL
00781210301 TACROLIMUS
68462031829 VIORELE
53489015610 ALLOPURINOL
67877019710 AMLODIPINE BESYLATE
00172409680 BACLOFEN
61314014410 BRIMONIDINE TARTRATE
68180072320 CEFDINIR
63304047901 CEVIMELINE HCL
00378022210 CHLORTHALIDONE
00555105686 CLARAVIS
57237001990 DULOXETINE HCL
62332002431 FLUOXETINE HCL
00002840001 FORTEO
68645051070 HYDROCHLOROTHIAZIDE
00093003901 LAMOTRIGINE
00093762056 LETROZOLE
43547035110 LISINOPRIL
68180051201 LISINOPRIL
16714043901 NITROFURANTOIN MONOHYDRAT
68462015713 ONDANSETRON ODT
00378660501 OXYBUTYNIN CHLORIDE ER
43547026910 ROPINIROLE HCL
00074929619 SYNTHROID
00093716356 TOLTERODINE TARTRATE ER
57237012001 WARFARIN SODIUM
00168042446 ADAPALENE
00781558315 ALTAVERA
68382022714 AMIODARONE HCL
00378261001 AMITRIPTYLINE HCL
00781148801 AMITRIPTYLINE HCL
68180075701 AMLODIPINE BESYLATE/BENAZ
00143988775 AMOXICILLIN
31722082030 ARIPIPRAZOLE
00185041505 BUPROPION HCL SR
00228253950 CARBIDOPA/LEVODOPA
65862014505 CARVEDILOL
00378730053 DROSPIRENONE/ETHINYL ESTR
00013215036 ESTRING
10370019105 GLIPIZIDE ER
00168014630 HYDROCORTISONE
68382009605 HYDROXYCHLOROQUINE SULFAT
23155050101 HYDROXYZINE HCL
68462035301 HYDROXYZINE HCL
00555902858 JUNEL FE 1.5/30
66758019001 KLOR-CON M20
00591060501 LABETALOL HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
25 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
51991077133 LANSOPRAZOLE
68645055554 LISINOPRIL
68180046907 LOVASTATIN
55111059760 MEMANTINE HCL
00169633910 NOVOLOG FLEXPEN
42806000501 OXYCODONE HCL
00597013554 PRADAXA
00597013560 PRADAXA
00143973910 PREDNISONE
00093535301 PROGESTERONE
16714045301 QUETIAPINE FUMARATE
68180044601 QUETIAPINE FUMARATE
55513007330 SENSIPAR
69097083305 SERTRALINE HCL
51862044601 TAMOXIFEN CITRATE
00093214062 TRI-LO-SPRINTEC
68462046160 TROSPIUM CHLORIDE
65862069730 VENLAFAXINE HCL ER
00065401303 VIGAMOX
51672402803 WARFARIN SODIUM
51672403301 WARFARIN SODIUM
61442011201 ACYCLOVIR
55111058601 AMLODIPINE BESYLATE/BENAZ
68382002201 ATENOLOL
00378395105 ATORVASTATIN CALCIUM
68645048054 ATORVASTATIN CALCIUM
00193731150 BAYER CONTOUR NEXT BLOOD
51862007901 CARBIDOPA/LEVODOPA
00093729501 CARVEDILOL
51672129303 CLOBETASOL PROPIONATE
66530024940 FLUOROURACIL
00832121310 JANTOVEN
68382000914 LAMOTRIGINE
00456120230 LINZESS
62332011231 METOPROLOL TARTRATE
00555901058 NORTREL 1/35
68180044501 QUETIAPINE FUMARATE
00093747243 RIZATRIPTAN BENZOATE
68180046503 SIMVASTATIN
61971011501 SULFAMETHOXAZOLE/TRIMETHO
64406000602 TECFIDERA
69543013611 TRAMADOL HCL
66530025445 TRETINOIN
16714036304 TRI-LINYAH
00527132601 URSODIOL
55111073005 ALLOPURINOL
59762307001 AZITHROMYCIN
68682037190 DILTIAZEM HCL ER
60505001608 DILT-XR
23155013525 DOXYCYCLINE MONOHYDRATE
16729009010 FINASTERIDE
16714035201 FLUOXETINE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
26 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378043101 GLIPIZIDE ER
00406012305 HYDROCODONE/ACETAMINOPHEN
31722054301 INDOMETHACIN
66758019092 KLOR-CON M20
50383077504 LIDOCAINE VISCOUS
00185007410 LOVASTATIN
50742015610 METFORMIN HCL
49483062350 METFORMIN HCL ER
00781223431 OMEPRAZOLE
59572063106 OTEZLA
42858010201 OXYCODONE/ACETAMINOPHEN
59011042010 OXYCONTIN
31722071290 PANTOPRAZOLE SODIUM
00574041205 POLYETHYLENE GLYCOL 3350
17478076710 PROGESTERONE
00049234045 RELPAX
54458093216 SIMVASTATIN
53746051501 SPIRONOLACTONE
16729004201 TACROLIMUS
00603002622 ASPIRIN EC LOW DOSE
00024585230 AVAPRO
00378115001 BUSPIRONE HCL
00378021301 CHLORTHALIDONE
16714059001 DIGOXIN
60505001508 DILT-XR
00378145801 ESTRADIOL
00378464026 ESTRADIOL
00591084510 GLIPIZIDE ER
00591261205 HYDROCODONE/ACETAMINOPHEN
65862053750 LEVOFLOXACIN
00781518992 LEVOTHYROXINE SODIUM
68180098201 LISINOPRIL
00555077902 MEDROXYPROGESTERONE ACETA
00781707787 METRONIDAZOLE VAGINAL
65162019011 NAPROXEN
00169750111 NOVOLOG
13107005501 OXYCODONE HCL
13107015590 PAROXETINE HCL
43547034809 PAROXETINE HCL
51991045757 POLYETHYLENE GLYCOL 3350
00093727098 PRAVASTATIN SODIUM
60505132309 PRAVASTATIN SODIUM
51991081801 PROPRANOLOL HCL ER
68180044801 QUETIAPINE FUMARATE
44087004403 REBIF
60505450503 ROSUVASTATIN CALCIUM
00591389201 SUCRALFATE
59746038506 TERAZOSIN HCL
16714050101 TERBINAFINE HCL
00603616121 TRAZODONE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
27 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
59417010210 VYVANSE
54092060601 XIIDRA
00406048410 ACETAMINOPHEN/CODEINE
64980015101 AMILORIDE HCL
00555097402 AMPHETAMINE/DEXTROAMPHETA
00904628889 ASPIRIN LOW DOSE
00185041060 BUPROPION HCL SR
00591354360 BUPROPION HCL SR
00310652401 BYETTA
60505384901 CELECOXIB
65862001905 CEPHALEXIN
68682099498 DILTIAZEM HCL ER
60505001506 DILT-XR
00093585205 ESCITALOPRAM OXALATE
00172572960 FAMOTIDINE
00054001025 FLECAINIDE ACETATE
50111064703 FLUOXETINE HCL
59762054102 GLIPIZIDE XL
68462030329 HEATHER
00406012501 HYDROCODONE/ACETAMINOPHEN
00185001001 LABETALOL HCL
65862039010 ONDANSETRON ODT
68462035701 POTASSIUM CHLORIDE ER
00378511001 PROCHLORPERAZINE MALEATE
16714045302 QUETIAPINE FUMARATE
68462025501 ROPINIROLE HCL
65862014736 SUMATRIPTAN SUCCINATE
50111091701 TORSEMIDE
00168000415 TRIAMCINOLONE ACETONIDE
00168000680 TRIAMCINOLONE ACETONIDE
00378253710 TRIAMTERENE/HYDROCHLOROTH
60505265701 TRIAMTERENE/HYDROCHLOROTH
00378341101 BUPROPION HCL SR
00591398401 CELECOXIB
00069046903 CHANTIX CONTINUING MONTH
54458098010 CITALOPRAM HYDROBROMIDE
00310075190 CRESTOR
00054418125 DEXAMETHASONE
00172392760 DIAZEPAM
68180090213 DROSPIRENONE/ETHINYL ESTR
68180029606 DULOXETINE HCL
69097084705 ESCITALOPRAM OXALATE
43547037609 IRBESARTAN
00832121410 JANTOVEN
00093031401 KETOROLAC TROMETHAMINE
66758017001 KLOR-CON M10
16714040703 LARIN 1.5/30
00603421232 LISINOPRIL
00378232101 LORAZEPAM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
28 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
59762374202 MEDROXYPROGESTERONE ACETA
62175031337 METHYLPHENIDATE HCL ER
57664051083 MIRTAZAPINE
16729009416 MYCOPHENOLATE MOFETIL
52544062928 NORA-BE
00093768432 OLOPATADINE HYDROCHLORIDE
68462039790 OMEPRAZOLE
00093573101 OXYCODONE HCL ER
61314020415 PILOCARPINE HCL
68462019705 PRAVASTATIN SODIUM
59746017110 PREDNISONE
60258015001 SF 5000 PLUS
00378072419 TIZANIDINE HCL
66530025345 TRETINOIN
43386033001 TRIMETHOPRIM
51862048601 TRIMETHOPRIM
00093738201 VENLAFAXINE HCL
68462029201 VERAPAMIL HCL ER
00093171901 WARFARIN SODIUM
00228203150 ALPRAZOLAM
16729017317 AMITRIPTYLINE HCL
60505057804 AZELASTINE HCL
68382009405 CARVEDILOL
00172392560 DIAZEPAM
49884051401 DIGOXIN
00085720601 DULERA
45963056730 EZETIMIBE/SIMVASTATIN
57237000630 FLUCONAZOLE
00093506105 HYDROXYZINE HCL
00832121210 JANTOVEN
31722053612 LEVETIRACETAM
68180050103 MELOXICAM
16729008110 NALTREXONE HCL
69097085512 NAPROXEN
61314064511 NEOMYCIN/POLYMYXIN/HYDROC
00781572010 POTASSIUM CHLORIDE ER
65162054450 PRIMIDONE
00603548221 PROPRANOLOL HCL
00603548321 PROPRANOLOL HCL
16729014601 QUETIAPINE FUMARATE
16714068302 SIMVASTATIN
12496120803 SUBOXONE
57664037718 TRAMADOL HCL
59417010410 VYVANSE
69097084407 ALFUZOSIN HCL ER
59762015702 ATORVASTATIN CALCIUM
68645046054 ATORVASTATIN CALCIUM
00781149668 AZITHROMYCIN
68180016013 AZITHROMYCIN
43598053760 BUPROPION HCL ER
00143178705 BUTALBITAL/ACETAMINOPHEN/
51862010206 CAMILA
00115521116 COLESTIPOL HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
29 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00555904958 CRYSELLE-28
00378423193 DESVENLAFAXINE ER
33342002710 DONEPEZIL HCL
00591248179 DORZOLAMIDE HCL
57237001930 DULOXETINE HCL
65862019201 FLUOXETINE HCL
16729003410 LETROZOLE
31722072250 LEVOFLOXACIN
68645055854 LISINOPRIL/HYDROCHLOROTHI
53746021905 METFORMIN HCL
00591272060 METFORMIN HCL ER
42858080101 MORPHINE SULFATE ER
13668009290 PRAMIPEXOLE DIHYDROCHLORI
00054474225 PREDNISONE
59746017310 PREDNISONE
59746017509 PREDNISONE
69452014920 PROGESTERONE
33342008850 RIZATRIPTAN BENZOATE
16729000615 SIMVASTATIN
60505025103 TIZANIDINE HCL
67877025145 TRIAMCINOLONE ACETONIDE
00093738001 VENLAFAXINE HCL
00093171801 WARFARIN SODIUM
51672402801 WARFARIN SODIUM
68180075801 AMLODIPINE BESYLATE/BENAZ
57237002801 AMOXICILLIN
17478021505 ATROPINE SULFATE
42799012001 BUMETANIDE
00378008501 CARBIDOPA/LEVODOPA
62037060090 CARTIA XT
59762374401 CLINDAMYCIN PHOSPHATE
54458088816 CLOPIDOGREL
59746021106 CYCLOBENZAPRINE HCL
50383023210 DORZOLAMIDE HCL
60505009400 DOXAZOSIN MESYLATE
66993066330 DULOXETINE HCL
00378464326 ESTRADIOL
60432003816 GENERLAC
00074379902 HUMIRA
31722051901 HYDRALAZINE HCL
43199001401 HYOSCYAMINE SULFATE ER
00527134610 LEVOTHYROXINE SODIUM
00603421132 LISINOPRIL
68180046803 LOVASTATIN
57664047453 METFORMIN HCL
00378617201 METOLAZONE
69097086707 NADOLOL
00186504031 NEXIUM
60505057501 OLOPATADINE HCL
00046110711 PREMPRO
00603548432 PROPRANOLOL HCL
31722051210 SIMVASTATIN
53489014405 SPIRONOLACTONE/HYDROCHLOR
00591079605 SULFASALAZINE
00781210201 TACROLIMUS
45802006435 TRIAMCINOLONE ACETONIDE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
30 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00591554401 ALLOPURINOL
00093753656 ANASTROZOLE
68462040467 ATOVAQUONE/PROGUANIL HCL
65862011801 BENAZEPRIL HCL
68382018314 BUSPIRONE HCL
00023585318 DELZICOL
61314001910 DORZOLAMIDE HCL
00378385777 ESCITALOPRAM OXALATE
68180036109 FENOFIBRATE
65862014905 FINASTERIDE
70461012010 FLUVIRIN 2017-2018
00591260505 HYDROCODONE/ACETAMINOPHEN
10702001001 HYDROXYZINE HCL
43547037409 IRBESARTAN
33342005807 IRBESARTAN/HYDROCHLOROTHI
00713067131 KETOCONAZOLE
00456120130 LINZESS
68645055654 LISINOPRIL/HYDROCHLOROTHI
68180046807 LOVASTATIN
29300017216 MEMANTINE HCL
55111064505 OMEPRAZOLE
51672411103 PHENYTOIN SODIUM EXTENDED
68462019690 PRAVASTATIN SODIUM
00046110381 PREMARIN
69543025810 PREPLUS
16714045402 QUETIAPINE FUMARATE
53746051105 SPIRONOLACTONE
12496120203 SUBOXONE
00074455290 SYNTHROID
00074706919 SYNTHROID
31722053101 TORSEMIDE
00002143380 TRULICITY
00378427593 VALACYCLOVIR HCL
65862044890 VALACYCLOVIR HCL
65862044990 VALACYCLOVIR HCL
62856024330 ACIPHEX
00781106110 ALPRAZOLAM
69097083705 AMLODIPINE BESYLATE
69097083715 AMLODIPINE BESYLATE
16729003515 ANASTROZOLE
31722082730 ARIPIPRAZOLE
00781107801 ATENOLOL
00093505998 ATORVASTATIN CALCIUM
43598053705 BUPROPION HCL ER
58914050156 CANASA
62037059905 CARTIA XT
65862007601 CIPROFLOXACIN HCL
51672408104 CLINDAMYCIN PHOSPHATE
43547027509 DONEPEZIL HCL
00002880359 HUMULIN 70/30 KWIKPEN
50111032701 HYDRALAZINE HCL
69367012207 HYDROCHLOROTHIAZIDE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
31 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378967130 IPRATROPIUM BROMIDE/ALBUT
00781518110 LEVOTHYROXINE SODIUM
68382048428 MESALAMINE DR
00054455025 METHOTREXATE
60505024901 MIRTAZAPINE
64980051505 OFLOXACIN
00832003800 OXYBUTYNIN CHLORIDE
47781019601 OXYCODONE/ACETAMINOPHEN
68382009705 PAROXETINE HCL
65862017601 PENICILLIN V POTASSIUM
00093727398 PIOGLITAZONE HCL
62175044231 POLYETHYLENE GLYCOL 3350
55111023090 PRAVASTATIN SODIUM
00228277911 PROPRANOLOL HCL ER
61314022710 TIMOLOL MALEATE
29300016915 TIZANIDINE HCL
68462015360 TOPIRAMATE
51672402703 WARFARIN SODIUM
31722077801 ACYCLOVIR
00487950125 ALBUTEROL SULFATE
00591554301 ALLOPURINOL
16729017501 AMITRIPTYLINE HCL
51991032390 ARMODAFINIL
54458088110 ATORVASTATIN CALCIUM
62332014231 CELECOXIB
00228212810 CLONIDINE HCL
00078060715 GILENYA
00603389121 HYDROCODONE/ACETAMINOPHEN
00054025222 IRBESARTAN
00054025513 IRBESARTAN/HYDROCHLOROTHI
66758019005 KLOR-CON M20
50383017290 LEVOCARNITINE
00527134410 LEVOTHYROXINE SODIUM
00527135101 LEVOTHYROXINE SODIUM
31722054501 LITHIUM CARBONATE
00378245710 LORAZEPAM
68645041170 LOSARTAN POTASSIUM
65862006301 METOPROLOL TARTRATE
00591521550 METRONIDAZOLE
60505083001 MOMETASONE FUROATE
00555913167 OCELLA
00603497528 OXYBUTYNIN CHLORIDE
65162037110 OXYBUTYNIN CHLORIDE ER
65862055990 PANTOPRAZOLE SODIUM
54458092516 PRAVASTATIN SODIUM
68462019505 PRAVASTATIN SODIUM
53489055101 PROPAFENONE HCL
61958100301 RANEXA
00781930301 TACROLIMUS
00781205301 TERAZOSIN HCL
00093171410 WARFARIN SODIUM
00093716956 AZITHROMYCIN
62037060005 CARTIA XT
00093417773 CEPHALEXIN
00472040060 CLOBETASOL PROPIONATE
00781178901 DICLOFENAC SODIUM DR
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
32 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378041510 DIPHENOXYLATE/ATROPINE
57237001890 DULOXETINE HCL
64380076304 DUTASTERIDE
00378710177 FENOFIBRATE
68645015159 GLIPIZIDE
59746038206 HYDROCHLOROTHIAZIDE
16714008210 HYDROXYZINE HCL
00591080001 HYDROXYZINE PAMOATE
68382001014 LAMOTRIGINE
62332006230 LEFLUNOMIDE
68180051401 LISINOPRIL
00378245701 LORAZEPAM
68645040954 LOSARTAN POTASSIUM
00071101268 LYRICA
68462038829 MARLISSA
65862001099 METFORMIN HCL
23155007001 METHIMAZOLE
00378035301 NIFEDIPINE ER
00093081001 NORTRIPTYLINE HCL
00052027301 NUVARING
60505014600 OMEPRAZOLE
59011044010 OXYCONTIN
59746011506 PROCHLORPERAZINE MALEATE
68462039301 RALOXIFENE HYDROCHLORIDE
00574024001 REPAGLINIDE
00074372790 SYNTHROID
16729004101 TACROLIMUS
00781205405 TERAZOSIN HCL
00591412879 TESTOSTERONE CYPIONATE
69097012203 TOPIRAMATE
00781506801 TRIAMTERENE/HYDROCHLOROTH
65597070118 WELCHOL
00781107901 ALPRAZOLAM
00781107905 ALPRAZOLAM
16729017401 AMITRIPTYLINE HCL
59762015602 ATORVASTATIN CALCIUM
60505258103 AZITHROMYCIN
00781208102 CALCIUM ACETATE
68462016301 CARVEDILOL
00378054101 CIMETIDINE
00555105786 CLARAVIS
00472098792 CLINDAMYCIN PHOSPHATE
00378047705 DIAZEPAM
60505299703 DULOXETINE HCL
51672403903 ENALAPRIL MALEATE
68462012605 GABAPENTIN
69315090410 LORAZEPAM
13107003105 MIRTAZAPINE
57237025530 MONTELUKAST SODIUM
00093101042 MUPIROCIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
33 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
16729009401 MYCOPHENOLATE MOFETIL
00185012201 NITROFURANTOIN MONOHYDRAT
00574200830 NYSTOP
62175027237 OXYBUTYNIN CHLORIDE ER
53746020401 OXYCODONE/ACETAMINOPHEN
68645049701 PANTOPRAZOLE SODIUM
61314020315 PILOCARPINE HCL
00378230201 PRAZOSIN HCL
59746017210 PREDNISONE
16729028415 ROSUVASTATIN CALCIUM
59746021701 SPIRONOLACTONE
53746027101 SULFAMETHOXAZOLE/TRIMETHO
61314064705 TOBRAMYCIN/DEXAMETHASONE
50111043402 TRAZODONE HCL
45802005536 TRIAMCINOLONE ACETONIDE
00093171301 WARFARIN SODIUM
67253090010 ALPRAZOLAM
00378262510 AMITRIPTYLINE HCL
00088250033 APIDRA
59762015502 ATORVASTATIN CALCIUM
00185012901 BUMETANIDE
00093005101 CARVEDILOL
60505384801 CELECOXIB
00185094098 CHOLESTYRAMINE
13668001101 CITALOPRAM HYDROBROMIDE
00115982201 DIGOXIN
10370083005 DILTIAZEM HCL ER
29300013901 DIVALPROEX SODIUM DR
00378402201 DOXAZOSIN MESYLATE
00378104901 DOXEPIN HCL
65162075009 DUTASTERIDE
53746010105 GABAPENTIN
00002871501 HUMULIN 70/30
16729018217 HYDROCHLOROTHIAZIDE
16714047401 HYDROXYCHLOROQUINE SULFAT
00555902742 JUNEL 1.5/30
51672129802 KETOCONAZOLE
16714070301 LAMOTRIGINE
68180011507 LEVETIRACETAM
13668011310 LOSARTAN POTASSIUM
62756014201 METFORMIN HCL ER
65862006499 METOPROLOL TARTRATE
00093733405 MYCOPHENOLATE MOFETIL
61314063006 NEOMYCIN/POLYMYXIN/DEXAME
00378727253 NORETHINDRONE
61314027105 OLOPATADINE HCL
00591270801 OXYCODONE HCL ER
59011043010 OXYCONTIN
00378700193 PAROXETINE HCL
53489014501 SULFAMETHOXAZOLE/TRIMETHO
00378226801 TERAZOSIN HCL
60505025203 TIZANIDINE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
34 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
45802006436 TRIAMCINOLONE ACETONIDE
00378644001 VERAPAMIL HCL ER
51248015003 VESICARE
68180078001 ZOLPIDEM TARTRATE ER
16714063201 ALENDRONATE SODIUM
42806005609 AMLODIPINE BESYLATE
64720013210 AMPHETAMINE/DEXTROAMPHETA
00781532531 BROMOCRIPTINE MESYLATE
49884050101 BUDESONIDE
42799012101 BUMETANIDE
00456141030 BYSTOLIC
66993087861 CALCIPOTRIENE
66993040932 CARBAMAZEPINE ER
00228253996 CARBIDOPA/LEVODOPA
65862014205 CARVEDILOL
00781217660 CEFDINIR
68180012101 CEPHALEXIN
60505001406 DILT-XR
00378047301 DIVALPROEX SODIUM ER
16729021101 DOXAZOSIN MESYLATE
16729021201 DOXAZOSIN MESYLATE
00713042950 DOXYCYCLINE MONOHYDRATE
68382070718 DOXYCYCLINE MONOHYDRATE
00008083321 EFFEXOR XR
00185536909 EPLERENONE
00781714483 ESTRADIOL
00781569031 EZETIMIBE
65862086001 FAMOTIDINE
69097045805 FENOFIBRATE
00406902576 FENTANYL
00054430129 FUROSEMIDE
67877022405 GABAPENTIN
16714010105 GEMFIBROZIL
00093725601 GLIMEPIRIDE
51672129803 KETOCONAZOLE
00456201001 LEXAPRO
00574022001 LIOTHYRONINE SODIUM
42794001902 LIOTHYRONINE SODIUM
00185007260 LOVASTATIN
65862001001 METFORMIN HCL
43386057401 METHYLPHENIDATE HCL
64720023910 METHYLPHENIDATE HCL
51862026301 METHYLPHENIDATE HCL ER
00591569401 MINOCYCLINE HCL
00781278531 OMEPRAZOLE
65862018730 ONDANSETRON HCL
65162037210 OXYBUTYNIN CHLORIDE ER
59011046010 OXYCONTIN
67253020111 PENICILLIN V POTASSIUM
33342005410 PIOGLITAZONE HCL
00574018105 POTASSIUM CHLORIDE ER
00143974010 PREDNISONE
00603764217 PREVIFEM
00115165901 PROPRANOLOL HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
35 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
69097084305 QUINAPRIL HCL
60505450409 ROSUVASTATIN CALCIUM
00093715298 SIMVASTATIN
16714068502 SIMVASTATIN
00056051030 SUSTIVA
00074518219 SYNTHROID
00074707090 SYNTHROID
67877014601 TEMAZEPAM
00143972601 TESTOSTERONE CYPIONATE
00169266015 TRESIBA FLEXTOUCH
00603766317 TRI-PREVIFEM
66582031354 VYTORIN
16714037003 WERA
00006496341 ZOSTAVAX
51862026006 ZOVIA 1/35E
23155022701 ACYCLOVIR
00378265001 AMITRIPTYLINE HCL
00378395205 ATORVASTATIN CALCIUM
00093542088 CABERGOLINE
00378363305 CARVEDILOL
59762374302 CLINDAMYCIN PHOSPHATE
00472040250 CLOBETASOL PROPIONATE
00378018601 CLONIDINE HCL
68546032512 COPAXONE
51991083801 CYPROHEPTADINE HCL
00310009530 DALIRESP
51862006305 DIAZEPAM
62332009391 DONEPEZIL HCL
68382078201 DOXYCYCLINE MONOHYDRATE
00065924007 DUREZOL
00093585201 ESCITALOPRAM OXALATE
47781020504 ESTRADIOL
00054001021 FLECAINIDE ACETATE
00093725401 GLIMEPIRIDE
23155000201 HYDRALAZINE HCL
51672300302 HYDROCORTISONE
00093506001 HYDROXYZINE HCL
49483060450 IBUPROFEN
47335047583 IMATINIB MESYLATE
68382065201 ISOSORBIDE MONONITRATE ER
00378510093 ITRACONAZOLE
29300011201 LAMOTRIGINE
00603421032 LISINOPRIL
68001026908 LISINOPRIL
54458088610 LISINOPRIL/HYDROCHLOROTHI
68645055754 LISINOPRIL/HYDROCHLOROTHI
68462022401 LITHIUM CARBONATE ER
68382005001 MELOXICAM
67253032010 METHOTREXATE
00591588201 METHYLPHENIDATE HCL
00406013601 METHYLPHENIDATE HCL ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
36 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00456342833 NAMENDA XR
00536589688 NICOTINE TRANSDERMAL SYST
68682010810 NIFEDIPINE ER
55111015330 ONDANSETRON HCL
47781046813 OSELTAMIVIR PHOSPHATE
00378661501 OXYBUTYNIN CHLORIDE ER
00054001829 PREDNISONE
00115166003 PROPRANOLOL HCL
16714045501 QUETIAPINE FUMARATE
47781030503 RIVASTIGMINE TRANSDERMAL
57237016890 ROSUVASTATIN CALCIUM
64764080530 ROZEREM
60258015101 SF
65162035109 SILDENAFIL
00004082205 TAMIFLU
24208029505 TOBRAMYCIN/DEXAMETHASONE
64764075030 TRINTELLIX
00131247835 VIMPAT
60505285001 ALFUZOSIN HCL ER
00603221232 AMITRIPTYLINE HCL
00093415573 AMOXICILLIN
51672134004 AUGMENTED BETAMETHASONE D
68180030320 CEFUROXIME AXETIL
00025152531 CELEBREX
00185006305 CLONAZEPAM
00555095302 DEXTROAMPHETAMINE SULFATE
00378402101 DOXAZOSIN MESYLATE
49884072601 DOXYCYCLINE MONOHYDRATE
68462073329 DROSPIRENONE/ETHINYL ESTR
51991074790 DULOXETINE HCL
00093645156 ESOMEPRAZOLE MAGNESIUM
00115703301 FLUDROCORTISONE ACETATE
24208034425 FLUNISOLIDE
49281041750 FLUZONE QUADRIVALENT 2017
61958190101 GENVOYA
49884006501 GLYCOPYRROLATE
50111032801 HYDRALAZINE HCL
31722054201 INDOMETHACIN
24208039830 IPRATROPIUM BROMIDE
00555902542 JUNEL 1/20
10147075004 KETOCONAZOLE
16714035601 LEVETIRACETAM
68180011216 LEVETIRACETAM
68180011316 LEVETIRACETAM
31722072320 LEVOFLOXACIN
00527134301 LEVOTHYROXINE SODIUM
17478071130 LIDOCAINE HCL JELLY
54458099410 LISINOPRIL
00591024201 LORAZEPAM
65862046890 LOSARTAN POTASSIUM/HYDROC
00406114401 METHYLPHENIDATE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
37 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
16729011917 MONTELUKAST SODIUM
00574200802 NYSTOP
54458098810 PAROXETINE HCL
00378046701 PIROXICAM
58468013001 RENVELA
59762100201 SIROLIMUS
44523056008 SODIUM SULFACETAMIDE/SULF
59746021601 SPIRONOLACTONE
55111029336 SUMATRIPTAN SUCCINATE
17478029010 TOBRAMYCIN SULFATE
00603616032 TRAZODONE HCL
67877025180 TRIAMCINOLONE ACETONIDE
67457034001 VANCOMYCIN HCL
00093015001 ACETAMINOPHEN/CODEINE
00115167934 ALENDRONATE SODIUM
64764008060 AMITIZA
67877019705 AMLODIPINE BESYLATE
68382020906 ANASTROZOLE
00093075301 ATENOLOL
69097089905 ATORVASTATIN CALCIUM
43547033610 BENAZEPRIL HCL
68382024701 BENZONATATE
60505015801 BUPROPION HCL
00093013501 CARVEDILOL
65862014305 CARVEDILOL
00093716501 CELECOXIB
00378715001 CELECOXIB
00713031788 CICLOPIROX NAIL LACQUER
45802014167 CICLOPIROX NAIL LACQUER
00603307932 CYCLOBENZAPRINE HCL
00781521801 DESIPRAMINE HCL
16571020106 DICLOFENAC SODIUM DR
61442010360 DICLOFENAC SODIUM DR
00187510001 ELIDEL
16714036504 ELINEST
16714044401 ENALAPRIL MALEATE
54505010202 EPINEPHRINE
13668013701 ESCITALOPRAM OXALATE
00378235193 ESOMEPRAZOLE MAGNESIUM
00093553901 ESZOPICLONE
42858066045 FENOFIBRATE
62559038001 FLECAINIDE ACETATE
00093542362 GIANVI
00378034093 GLIPIZIDE ER
10702001201 HYDROXYZINE HCL
68462030201 INDOMETHACIN
24208000403 ISTALOL
13811067830 LEFLUNOMIDE
16714035701 LEVETIRACETAM
00781518092 LEVOTHYROXINE SODIUM
00603188016 LIDOCAINE
00378207501 LISINOPRIL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
38 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
43547035550 LISINOPRIL
68180051501 LISINOPRIL
68645040970 LOSARTAN POTASSIUM
00378718705 METFORMIN HCL
00603448521 METHOCARBAMOL
50111033402 METRONIDAZOLE
52544016528 NECON 7/7/7
00536110888 NICOTINE TRANSDERMAL SYST
55111015430 ONDANSETRON HCL
00054055125 OXYCODONE/ACETAMINOPHEN
00406052201 OXYCODONE/ACETAMINOPHEN
13107015790 PAROXETINE HCL
00472024260 PERMETHRIN
00093727298 PIOGLITAZONE HCL
33342005507 PIOGLITAZONE HCL
44946104501 PNV PRENATAL PLUS MULTIVI
16729000915 PRAVASTATIN SODIUM
00143973810 PREDNISONE
24208060203 PROLENSA
66993011560 PROPAFENONE HCL ER
62175030232 RABEPRAZOLE SODIUM
68462024920 RANITIDINE HCL
00574024101 REPAGLINIDE
68462025301 ROPINIROLE HCL
31722051290 SIMVASTATIN
60505015900 SOTALOL HCL
00074455219 SYNTHROID
49281021515 TENIVAC
00093001006 TOLTERODINE TARTRATE
69097012312 TOPIRAMATE
60505265901 TRAZODONE HCL
00093171201 WARFARIN SODIUM
00093171601 WARFARIN SODIUM
00187073130 WELLBUTRIN XL
00487950160 ALBUTEROL SULFATE
42806005505 AMLODIPINE BESYLATE
00115149101 AMPHETAMINE/DEXTROAMPHETA
57664064408 AMPHETAMINE/DEXTROAMPHETA
00093202631 AZITHROMYCIN
00168016260 CLOBETASOL PROPIONATE
00143301801 COLCHICINE
00378161005 DICYCLOMINE HCL
00378047201 DIVALPROEX SODIUM ER
00378116001 GUANFACINE HCL
29300013010 HYDROCHLOROTHIAZIDE
76439030910 HYOSCYAMINE SULFATE
00069018921 IBRANCE
00555912366 JOLESSA
66758016005 KLOR-CON 10
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
39 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68382001601 LEVOFLOXACIN
00378728153 LEVONORGESTREL/ETHINYL ES
00378181977 LEVOTHYROXINE SODIUM
00185064001 LISINOPRIL
68180033707 METFORMIN HCL ER
00591588401 METHYLPHENIDATE HCL
13811070810 METHYLPHENIDATE HCL ER
65862006299 METOPROLOL TARTRATE
51672411606 METRONIDAZOLE
60505132101 MIDODRINE HCL
00054025922 MONTELUKAST SODIUM
65862057490 MONTELUKAST SODIUM
57237007810 ONDANSETRON ODT
53885024510 ONETOUCH ULTRA BLUE
53885039310 ONETOUCH ULTRASOFT LANCET
00093573201 OXYCODONE HCL ER
00228298211 OXYCODONE/ACETAMINOPHEN
00121075908 PREDNISOLONE SODIUM PHOSP
68382006710 SIMVASTATIN
59746021801 SPIRONOLACTONE
55111029309 SUMATRIPTAN SUCCINATE
00781205201 TERAZOSIN HCL
00143965901 TESTOSTERONE CYPIONATE
68462010860 TOPIRAMATE
50111043403 TRAZODONE HCL
00049491030 ZOLOFT
00781107701 ALPRAZOLAM
42806005709 AMLODIPINE BESYLATE
67877019905 AMLODIPINE BESYLATE
31722081930 ARIPIPRAZOLE
58468021002 AUBAGIO
61314030802 AZELASTINE HCL
00093202623 AZITHROMYCIN
45802002146 BETAMETHASONE DIPROPIONAT
00378043501 BUPROPION HCL
00591336901 BUTALBITAL/ACETAMINOPHEN/
68180030260 CEFUROXIME AXETIL
00093314505 CEPHALEXIN
65862001801 CEPHALEXIN
00093206506 CILOSTAZOL
00172531260 CIPROFLOXACIN HCL
00168020260 CLINDAMYCIN PHOSPHATE
50383026860 CLOBETASOL PROPIONATE
00591350804 CLONIDINE HCL
29300013601 CLONIDINE HCL
00472080415 DESONIDE
64764017590 DEXILANT
00378027105 DIAZEPAM
10370082905 DILTIAZEM HCL ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
40 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68682036890 DILTIAZEM HCL ER
68180029506 DULOXETINE HCL
00781342868 ENOXAPARIN SODIUM
47781020604 ESTRADIOL
00115552210 FENOFIBRATE
68382027016 FENOFIBRATE
68645054154 FINASTERIDE
00555099702 FLUDROCORTISONE ACETATE
60758061525 GATIFLOXACIN
65162071110 GUANFACINE HCL
00002880559 HUMULIN N KWIKPEN
31722052201 HYDRALAZINE HCL
00228282011 HYDROCHLOROTHIAZIDE
43547037403 IRBESARTAN
00832121200 JANTOVEN
00193288050 KETOSTIX
51991077290 LANSOPRAZOLE
31722053812 LEVETIRACETAM
00527134701 LEVOTHYROXINE SODIUM
00603421134 LISINOPRIL
00378130005 LITHIUM CARBONATE ER
00378232105 LORAZEPAM
00591024205 LORAZEPAM
68180021609 LOSARTAN POTASSIUM/HYDROC
69097015807 MELOXICAM
31722053405 METHOCARBAMOL
64720023810 METHYLPHENIDATE HCL
59762444002 METHYLPREDNISOLONE DOSE P
00093220401 METOCLOPRAMIDE HCL
23155005519 NARATRIPTAN HCL
61314063136 NEOMYCIN/POLYMYXIN/DEXAME
68462013281 NORETHINDRONE ACETATE/ETH
00472016330 NYSTATIN
60505006502 OMEPRAZOLE
00832003850 OXYBUTYNIN CHLORIDE
60432009216 OXYBUTYNIN CHLORIDE
00378661001 OXYBUTYNIN CHLORIDE ER
64764054411 PREVACID SOLUTAB
00093777179 RISEDRONATE SODIUM
16729028515 ROSUVASTATIN CALCIUM
68645048870 SERTRALINE HCL
00093106001 SOTALOL HCL
53489032905 SPIRONOLACTONE
00002322930 STRATTERA
65862049647 SULFAMETHOXAZOLE/TRIMETHO
45802070000 TACROLIMUS
66758020854 TRANSDERM-SCOP
45802005535 TRIAMCINOLONE ACETONIDE
56151014260 TRUEPLUS LANCETS 28G
65862052730 VENLAFAXINE HCL ER
69543013104 ALENDRONATE SODIUM
00603210902 AMLODIPINE BESYLATE
00143995101 AMOXICILLIN
00781615746 AMOXICILLIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
41 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
65862050220 AMOXICILLIN/CLAVULANATE P
13107006801 AMPHETAMINE/DEXTROAMPHETA
68645045954 ATORVASTATIN CALCIUM
69097089915 ATORVASTATIN CALCIUM
59762306002 AZITHROMYCIN
68180016006 AZITHROMYCIN
64380078706 BUSPIRONE HCL
62037059990 CARTIA XT
68462016505 CARVEDILOL
68180039701 CELECOXIB
00093206406 CILOSTAZOL
00713474101 CITALOPRAM HYDROBROMIDE
16714048501 DIVALPROEX SODIUM ER
53746010205 GABAPENTIN
54458096610 GLIMEPIRIDE
00781145301 GLIPIZIDE
16729018301 HYDROCHLOROTHIAZIDE
00093506201 HYDROXYZINE HCL
60505279500 IBANDRONATE SODIUM
68180041109 IRBESARTAN
00832121110 JANTOVEN
00168009960 KETOCONAZOLE
00713067160 KETOCONAZOLE
68180084413 KURVELO
68382000601 LAMOTRIGINE
31722055190 LEVOCETIRIZINE DIHYDROCHL
33342002208 LEVOFLOXACIN
00378655053 LEVONORGESTREL/ETHINYL ES
00527134201 LEVOTHYROXINE SODIUM
00185017310 LISINOPRIL/HYDROCHLOROTHI
68462022110 LITHIUM CARBONATE
00093736610 LOSARTAN POTASSIUM
68180021606 LOSARTAN POTASSIUM/HYDROC
00185007060 LOVASTATIN
23155010301 METFORMIN HCL
68382077501 METHOTREXATE
66993096159 METRONIDAZOLE
00093720756 MIRTAZAPINE
00054051744 MORPHINE SULFATE
00406117001 NALTREXONE HCL
65162032109 NIACIN ER
65162032309 NIACIN ER
00378039001 NIFEDIPINE ER
00169770421 NORDITROPIN FLEXPRO
43598016430 OLANZAPINE
57237016199 OMEPRAZOLE
43547034909 PAROXETINE HCL
00603154258 POTASSIUM CHLORIDE
69543037930 POTASSIUM CHLORIDE
00046110611 PREMPRO
10631040701 PROCTOSOL HC
64980032430 PROCTOZONE-HC
51991082001 PROPRANOLOL HCL ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
42 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
65162025425 RANITIDINE HCL
16252061830 ROSUVASTATIN CALCIUM
68462026190 ROSUVASTATIN CALCIUM
65862092127 SEVELAMER CARBONATE
00093204905 TOLTERODINE TARTRATE ER
13668019030 TOLTERODINE TARTRATE ER
68382014114 TOPIRAMATE
00168000615 TRIAMCINOLONE ACETONIDE
00591315901 URSODIOL
00169517603 VAGIFEM
50383079216 VALPROIC ACID
43547036909 VALSARTAN
00469012599 XTANDI
10370011610 ZOLPIDEM TARTRATE ER
68462039429 ALYACEN 1/35
68382012205 AMLODIPINE BESYLATE
00555097102 AMPHETAMINE/DEXTROAMPHETA
51991032490 ARMODAFINIL
60219107601 AZATHIOPRINE
00093202723 AZITHROMYCIN
59762307002 AZITHROMYCIN
67877057305 BENZONATATE
00115681110 BUPROPION HCL XL
64380072306 CALCITRIOL
68382009505 CARVEDILOL
50474071079 CIMZIA
13668000901 CITALOPRAM HYDROBROMIDE
00555105586 CLARAVIS
50383026815 CLOBETASOL PROPIONATE
50383026830 CLOBETASOL PROPIONATE
47335089481 CLOPIDOGREL
00115981103 DIGOXIN
59762003802 DOFETILIDE
60505009300 DOXAZOSIN MESYLATE
13668013601 ESCITALOPRAM OXALATE
00378464426 ESTRADIOL
00054429725 FUROSEMIDE
00378020801 FUROSEMIDE
50383031147 GABAPENTIN
69097081207 GABAPENTIN
50383018902 GATIFLOXACIN
00002771227 HUMALOG KWIKPEN
50111039701 HYDRALAZINE HCL
45802001402 HYDROCORTISONE
00406324401 HYDROMORPHONE HCL
16714008211 HYDROXYZINE HCL
00115167101 HYDROXYZINE PAMOATE
44183044001 ISOMETHEPTENE/DICHLORALPH
00832121850 JANTOVEN
49884012201 LABETALOL HCL
00904600760 LORAZEPAM
00071101868 LYRICA
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
43 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
59746012106 MECLIZINE HCL
29300012501 MELOXICAM
00185441601 METFORMIN HCL ER
64720023710 METHYLPHENIDATE HCL
00378815877 METHYLPHENIDATE HCL ER
65649020175 MOVIPREP
00093747701 MYCOPHENOLATE MOFETIL
47335053981 NIACIN ER
00904573511 NICORELIEF
00555021110 NORETHINDRONE ACETATE
51672400202 NORTRIPTYLINE HCL
51862001701 NORTRIPTYLINE HCL
51862001801 NORTRIPTYLINE HCL
00093540189 OMEGA-3-ACID ETHYL ESTERS
00781223401 OMEPRAZOLE
62175011843 OMEPRAZOLE
00591269301 OXYCODONE HCL ER
13107004401 OXYCODONE/ACETAMINOPHEN
68382000106 PAROXETINE HCL
00115166101 PROPRANOLOL HCL
16729014701 QUETIAPINE FUMARATE
55513076002 REPATHA SURECLICK
33342009372 RIZATRIPTAN BENZOATE ODT
53489014605 SULFAMETHOXAZOLE/TRIMETHO
45802011639 TESTOSTERONE
00378072219 TIZANIDINE HCL
29300016815 TIZANIDINE HCL
00472011745 TRETINOIN
00527163201 TRIAMTERENE/HYDROCHLOROTH
00456112030 VIIBRYD
57237012501 WARFARIN SODIUM
50383007916 ACETAMINOPHEN/CODEINE
00023932110 ALPHAGAN P
64764024060 AMITIZA
00093737101 AMLODIPINE BESYLATE/BENAZ
66685100200 AMOXICILLIN/CLAVULANATE P
27241005203 ARIPIPRAZOLE
43598055830 ARIPIPRAZOLE
00093202694 AZITHROMYCIN
64380071306 BENZONATATE
00185041560 BUPROPION HCL SR
00378200877 BUPROPION HCL XL
16729007901 CARBIDOPA/LEVODOPA ER
69097042112 CELECOXIB
65862000601 CITALOPRAM HYDROBROMIDE
65862018501 CLINDAMYCIN HCL
00472098791 CLINDAMYCIN PHOSPHATE
00093083210 CLONAZEPAM
00378191405 CLONAZEPAM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
44 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378015210 CLONIDINE HCL
00378362705 CLOPIDOGREL
16571020210 DICLOFENAC SODIUM DR
60505001408 DILT-XR
59762232006 DOXAZOSIN MESYLATE
47335038383 DULOXETINE HCL
50458009801 ELMIRON
45802096694 ERYTHROMYCIN
00378335099 ESTRADIOL
00054008013 EXEMESTANE
00172572880 FAMOTIDINE
68462010430 FLUCONAZOLE
00472082902 FLUOCINONIDE
00093360882 FLUTICASONE PROPIONATE/SA
31722052101 HYDRALAZINE HCL
49483060350 IBUPROFEN
00781176201 IMIPRAMINE HCL
76204060030 IPRATROPIUM BROMIDE/ALBUT
00093823298 IRBESARTAN/HYDROCHLOROTHI
49884000901 ISOSORBIDE DINITRATE
31722057447 LEVETIRACETAM
65862053820 LEVOFLOXACIN
68180084313 LEVONORGESTREL/ETHINYL ES
00527135010 LEVOTHYROXINE SODIUM
00054350049 LIDOCAINE VISCOUS
00591207030 LIDOCAINE/PRILOCAINE
24208050307 LOTEMAX
00555087202 MEDROXYPROGESTERONE ACETA
00378354752 MERCAPTOPURINE
00378617301 METOLAZONE
00781708035 METRONIDAZOLE
00115165701 NABUMETONE
00536110788 NICOTINE TRANSDERMAL SYST
68682010510 NIFEDIPINE ER
00093081101 NORTRIPTYLINE HCL
00093577056 OLANZAPINE
60505014602 OMEPRAZOLE
54838051080 OXYBUTYNIN CHLORIDE
42858000301 OXYCODONE HCL
00228298311 OXYCODONE/ACETAMINOPHEN
53746020301 OXYCODONE/ACETAMINOPHEN
00603156758 PREDNISOLONE
00603548421 PROPRANOLOL HCL
00186091706 PULMICORT FLEXHALER
00115351101 PYRIDOSTIGMINE BROMIDE
60505313201 QUETIAPINE FUMARATE
00121072716 RANITIDINE HCL
00093330416 RECLIPSEN
00003362212 REYATAZ
51991035578 RIZATRIPTAN BENZOATE
45802089626 SULFACETAMIDE SODIUM
00074434190 SYNTHROID
65862007930 TERBINAFINE HCL
00093001806 TOLTERODINE TARTRATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
45 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00093205056 TOLTERODINE TARTRATE ER
69097081603 TOPIRAMATE
50111091601 TORSEMIDE
16714048103 TRAMADOL HCL
00093738301 VENLAFAXINE HCL
13668000705 ZOLPIDEM TARTRATE
57894015012 ZYTIGA
50924088401 ACCU-CHEK COMPACT PLUS
16252059944 ALENDRONATE SODIUM
16714063302 ALENDRONATE SODIUM
68180076001 AMLODIPINE BESYLATE/BENAZ
00172524160 ANAGRELIDE HYDROCHLORIDE
00713050324 ANUCORT-HC
60505267303 ARIPIPRAZOLE
68382002410 ATENOLOL
69097089805 ATORVASTATIN CALCIUM
66993006002 ATOVAQUONE/PROGUANIL HCL
58160084252 BOOSTRIX
00173085914 BREO ELLIPTA
00310652004 BYDUREON
00378007801 CARBIDOPA/LEVODOPA
00378009401 CARBIDOPA/LEVODOPA ER
65162005250 CITALOPRAM HYDROBROMIDE
00228300350 CLONAZEPAM
68968052508 COMBIPATCH
00009003101 CORTEF
00032121201 CREON
10702000650 CYCLOBENZAPRINE HCL
00591366030 DESVENLAFAXINE ER
59762122203 DESVENLAFAXINE ER
00378162001 DICYCLOMINE HCL
16714059101 DIGOXIN
00093761843 DORZOLAMIDE HCL
61314003002 DORZOLAMIDE HCL/TIMOLOL M
00115169449 EPINEPHRINE
00093553801 ESZOPICLONE
00591371319 EZETIMIBE
00115052201 FENOFIBRATE MICRONIZED
00781724055 FENTANYL
55111014512 FLUCONAZOLE
51672135708 FLUOCINOLONE ACETONIDE SC
00378073501 FLUOXETINE HCL
16714035301 FLUOXETINE HCL
00228285311 GUANFACINE ER
23155000301 HYDRALAZINE HCL
66993005704 HYDROXYCHLOROQUINE SULFAT
16714008212 HYDROXYZINE HCL
68645053154 IBUPROFEN
00054025522 IRBESARTAN/HYDROCHLOROTHI
00832121400 JANTOVEN
66758020505 KLOR-CON SPRINKLE
49884012401 LABETALOL HCL
16714040803 LARIN 1/20
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
46 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68180011416 LEVETIRACETAM
00591301230 LIDOCAINE HCL JELLY
16729037817 LISINOPRIL
43547036111 LOSARTAN POTASSIUM
24208029905 LOTEMAX
44946100903 LUDENT
00023320505 LUMIGAN
00555017178 MEFLOQUINE HCL
68382064928 MESALAMINE DR
43547035950 METFORMIN HCL
00378061101 METHYLDOPA
68001012203 METOPROLOL SUCCINATE ER
57237010099 METOPROLOL TARTRATE
68645019159 METOPROLOL TARTRATE
00193658621 MICROLET LANCETS
59762500701 MISOPROSTOL
29300022010 MONTELUKAST SODIUM
57237021330 MONTELUKAST SODIUM
00781713593 MOXIFLOXACIN HCL
00169185250 NOVOFINE 30GX8MM
45802005911 NYSTATIN
51991029201 OXCARBAZEPINE
59011041510 OXYCONTIN
00093001198 PANTOPRAZOLE SODIUM
13668009690 PANTOPRAZOLE SODIUM
59746028490 PANTOPRAZOLE SODIUM
54458098910 PAROXETINE HCL
57237004101 PENICILLIN V POTASSIUM
45802026937 PERMETHRIN
33342003110 PRAMIPEXOLE DIHYDROCHLORI
16729001015 PRAVASTATIN SODIUM
00378320501 PRAZOSIN HCL
00054474125 PREDNISONE
68382065901 PYRIDOSTIGMINE BROMIDE
51991068333 RABEPRAZOLE SODIUM
16252057250 RAMIPRIL
68462026290 ROSUVASTATIN CALCIUM
16714061104 SERTRALINE HCL
52343002545 SIMVASTATIN
00002323930 STRATTERA
53746027201 SULFAMETHOXAZOLE/TRIMETHO
68382013210 TAMSULOSIN HCL
00078050905 TEGRETOL
00093204998 TOLTERODINE TARTRATE ER
00186108805 TOPROL XL
66530025545 TRETINOIN
45802006535 TRIAMCINOLONE ACETONIDE
00378135201 TRIAMTERENE/HYDROCHLOROTH
17478070311 TRIMETHOPRIM SULFATE/POLY
16714069703 VALACYCLOVIR HCL
43547036809 VALSARTAN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
47 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378212001 VERAPAMIL HCL ER
57237012201 WARFARIN SODIUM
00054008525 ZALEPLON
52544038428 ZOVIA 1/50E
45802045384 ADAPALENE
76204020030 ALBUTEROL SULFATE
42806005610 AMLODIPINE BESYLATE
00093415580 AMOXICILLIN
00093227534 AMOXICILLIN/CLAVULANATE P
00406889201 AMPHETAMINE/DEXTROAMPHETA
13107007201 AMPHETAMINE/DEXTROAMPHETA
13668021930 ARIPIPRAZOLE
00085134102 ASMANEX TWISTHALER 60 MET
00781538192 ATORVASTATIN CALCIUM
00591376830 BUDESONIDE
00378114005 BUSPIRONE HCL
23155011901 CALCITRIOL
00054008826 CALCIUM ACETATE
65862021960 CEFDINIR
68180072310 CEFDINIR
49884046565 CHOLESTYRAMINE
00093820401 CIMETIDINE
61314065605 CIPROFLOXACIN HCL
65162005303 CITALOPRAM HYDROBROMIDE
00555105756 CLARAVIS
00591570801 CLINDAMYCIN HCL
69097084507 CYCLOBENZAPRINE HCL
64720015010 CYPROHEPTADINE HCL
60505009600 DOXAZOSIN MESYLATE
43598058530 EZETIMIBE/SIMVASTATIN
00406901276 FENTANYL
00406905076 FENTANYL
58657015010 FOLIC ACID
45963055650 GABAPENTIN
59762054001 GLIPIZIDE XL
00002803101 GLUCAGON EMERGENCY KIT
51862022701 HYDROCODONE/ACETAMINOPHEN
53746046405 IBUPROFEN
00832121600 JANTOVEN
00597015230 JARDIANCE
66758020501 KLOR-CON SPRINKLE
00185011701 LABETALOL HCL
69097014907 LAMOTRIGINE
55111071930 LAMOTRIGINE ER
63402030230 LATUDA
00591292754 LEVALBUTEROL TARTRATE HFA
50383066730 LIDOCAINE/PRILOCAINE
00185061001 LISINOPRIL
43547035510 LISINOPRIL
00054252625 LITHIUM CARBONATE
00603424628 LORAZEPAM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
48 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
59746033410 LOSARTAN POTASSIUM
68180046701 LOVASTATIN
00071101768 LYRICA
52544069230 MATZIM LA
65162044210 MECLIZINE HCL
29300017116 MEMANTINE HCL
00406144501 METHYLPHENIDATE HCL ER
00115147446 METRONIDAZOLE
59762500801 MISOPROSTOL
00456342890 NAMENDA XR
24979001001 NIFEDIPINE ER
62175026055 NIFEDIPINE ER
00093576801 OLANZAPINE
64980051705 OLOPATADINE HCL
62175027037 OXYBUTYNIN CHLORIDE ER
68382079401 OXYCODONE HCL
62175018046 PANTOPRAZOLE SODIUM
75826011510 PHENAZOPYRIDINE HCL
62175044215 POLYETHYLENE GLYCOL 3350
60505132305 PRAVASTATIN SODIUM
00005197102 PREVNAR 13
00115165903 PROPRANOLOL HCL
00591555610 PROPRANOLOL HCL
00228278011 PROPRANOLOL HCL ER
00093816601 QUETIAPINE FUMARATE
67877024210 QUETIAPINE FUMARATE
68382014601 RAMIPRIL
27241000306 RISPERIDONE
68180035106 SERTRALINE HCL
53489014301 SPIRONOLACTONE
00002325030 STRATTERA
00378563159 SUMATRIPTAN SUCCINATE
65862014636 SUMATRIPTAN SUCCINATE
24090049584 TIROSINT
61314064305 TOBRAMYCIN SULFATE
00093716498 TOLTERODINE TARTRATE ER
50111091501 TORSEMIDE
43478024245 TRETINOIN
00378141105 VERAPAMIL HCL ER
00069422030 VIAGRA
17478060930 ZIOPTAN
00378531005 ZOLPIDEM TARTRATE
60505530601 ACYCLOVIR
66302046760 ADCIRCA
16714044602 AMITRIPTYLINE HCL
00093226301 AMOXICILLIN
00085134101 ASMANEX TWISTHALER 120 ME
68645048170 ATORVASTATIN CALCIUM
59627033304 AVONEX PEN
00832102450 BACLOFEN
16714007204 BACLOFEN
00378052493 BISOPROLOL FUMARATE
00781106401 BUPROPION HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
49 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00527155201 BUTALBITAL/ASPIRIN/CAFFEI
00093747489 CAPECITABINE
00378113301 CARBIDOPA/LEVODOPA
62756051813 CARBIDOPA/LEVODOPA
16714038801 CEFADROXIL
00002446230 CIALIS
54458088910 CITALOPRAM HYDROBROMIDE
54458098016 CITALOPRAM HYDROBROMIDE
45802026337 CLINDAMYCIN PHOSPHATE
16714047001 CLONAZEPAM
00228212850 CLONIDINE HCL
29300013505 CLONIDINE HCL
68645051890 CYCLOBENZAPRINE HCL
00591246501 DESMOPRESSIN ACETATE
00054418325 DEXAMETHASONE
00378606001 DILTIAZEM HCL ER
59762106101 DIPHENOXYLATE/ATROPINE
13668011105 DULOXETINE HCL
59762232201 ELETRIPTAN HYDROBROMIDE
58406045504 ENBREL
00378385677 ESCITALOPRAM OXALATE
68180013701 ESCITALOPRAM OXALATE
00591371330 EZETIMIBE
00093026430 FLUOCINONIDE
55111028448 FLUOXETINE DR
00093444405 GABAPENTIN
00093725652 GLIMEPIRIDE
16729000101 GLIMEPIRIDE
00378313201 GLIPIZIDE/METFORMIN HCL
00093834410 GLYBURIDE
00228257111 INDAPAMIDE
62175012837 ISOSORBIDE MONONITRATE ER
00597015290 JARDIANCE
60758077305 KETOROLAC TROMETHAMINE
55111028050 LEVOFLOXACIN
65862053650 LEVOFLOXACIN
00591040810 LISINOPRIL
54458099210 LISINOPRIL/HYDROCHLOROTHI
66869010490 LIVALO
13668040910 LOSARTAN POTASSIUM
68382013510 LOSARTAN POTASSIUM
69097015915 MELOXICAM
67877056310 METFORMIN HCL
60505026002 METFORMIN HCL ER
43386016106 MISOPROSTOL
00078038566 MYFORTIC
24208063110 NEOMYCIN/POLYMYXIN/HC
00065000203 NEVANAC
68645051354 NIFEDIPINE ER
00378729253 NORETHINDRONE
51672400305 NORTRIPTYLINE HCL
00472016630 NYSTATIN
50383058716 NYSTATIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
50 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
63304045830 ONDANSETRON HCL
00603497521 OXYBUTYNIN CHLORIDE
68382009906 PAROXETINE HCL
00378200493 PAROXETINE HCL ER
10702000350 PROMETHAZINE HCL
60505313001 QUETIAPINE FUMARATE
64380080438 RANITIDINE HCL
16252061530 ROSUVASTATIN CALCIUM
68645048970 SERTRALINE HCL
00065414727 SIMBRINZA
00597016061 SPIRIVA RESPIMAT
00603576521 SPIRONOLACTONE
65862041901 SULFAMETHOXAZOLE/TRIMETHO
00378053101 SULINDAC
42806001105 SULINDAC
59746038606 TERAZOSIN HCL
70069013101 TOBRAMYCIN
43478024145 TRETINOIN
00378581477 VALSARTAN
68462026001 VERAPAMIL HCL ER
68462029305 VERAPAMIL HCL ER
59417010510 VYVANSE
00093172110 WARFARIN SODIUM
00093526901 ZALEPLON
69543012210 ACARBOSE
68382079201 ACYCLOVIR
66993088445 ADAPALENE
57844012001 ADDERALL
00591554405 ALLOPURINOL
16714004110 ALLOPURINOL
65862073205 AMIODARONE HCL
00603221332 AMITRIPTYLINE HCL
10144042760 AMPYRA
00456046001 ARMOUR THYROID
00904770418 ASPIR-LOW
00781150601 ATENOLOL
00093505898 ATORVASTATIN CALCIUM
47335077991 AZELASTINE HCL
60505084805 AZELASTINE HCL
59762313001 AZITHROMYCIN
00168005615 BETAMETHASONE DIPROPIONAT
16714057102 BICALUTAMIDE
00093681673 BUDESONIDE
00115169202 BUSPIRONE HCL
16729028912 BUSPIRONE HCL
49884072501 BUSPIRONE HCL
51672404101 CARBAMAZEPINE
00781598801 CARBAMAZEPINE ER
00378363405 CARVEDILOL
68001015200 CARVEDILOL
68001015203 CARVEDILOL
68382009305 CARVEDILOL
65862090901 CELECOXIB
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
51 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68180012401 CEPHALEXIN
68180012402 CEPHALEXIN
00713063831 CICLOPIROX OLAMINE
16571012050 CIPROFLOXACIN HCL
69097082407 CITALOPRAM HYDROBROMIDE
69097082412 CITALOPRAM HYDROBROMIDE
00527193206 CLARITHROMYCIN
51672125802 CLOBETASOL PROPIONATE
51672125903 CLOBETASOL PROPIONATE
29300013610 CLONIDINE HCL
00054414622 CLOTRIMAZOLE
68546031730 COPAXONE
00056017270 COUMADIN
00378729653 DESOGESTREL/ETHINYL ESTRA
00054417925 DEXAMETHASONE
64764017130 DEXILANT
10702010801 DEXMETHYLPHENIDATE HCL
00781501701 DICLOFENAC POTASSIUM
00378161001 DICYCLOMINE HCL
00071374066 DILANTIN
00093032001 DILTIAZEM HCL
00378528001 DILTIAZEM HCL ER
55111053201 DIVALPROEX SODIUM
51862000560 DOFETILIDE
16729021401 DOXAZOSIN MESYLATE
16729041501 DOXAZOSIN MESYLATE
51991074890 DULOXETINE HCL
65162075003 DUTASTERIDE
68645045790 ENALAPRIL MALEATE
51672404501 ENALAPRIL MALEATE/HYDROCH
00703868023 ENOXAPARIN SODIUM
00555904758 ENPRESSE-28
65862084130 ENTECAVIR
00185536809 EPLERENONE
51862010006 ERRIN
00378334999 ESTRADIOL
45963056830 EZETIMIBE/SIMVASTATIN
68001024100 FAMOTIDINE
00310621030 FARXIGA
00591321372 FENTANYL
60505700602 FENTANYL
00597005801 FLOMAX
00093026230 FLUOCINONIDE
43199003160 FLUOCINONIDE
49909000530 FLUOXETINE HCL
63304063201 FLUOXETINE HCL
00378041201 FLUVOXAMINE MALEATE
00378021601 FUROSEMIDE
00378023205 FUROSEMIDE
57237002405 GLYBURIDE/METFORMIN HCL
00378025701 HALOPERIDOL
29300013001 HYDROCHLOROTHIAZIDE
68645051154 HYDROCHLOROTHIAZIDE
69315013501 IMIPRAMINE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
52 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
45802036862 IMIQUIMOD
00228259711 INDAPAMIDE
00378006901 INDAPAMIDE
00378008001 INDAPAMIDE
68180041206 IRBESARTAN
00054025422 IRBESARTAN/HYDROCHLOROTHI
00006022761 ISENTRESS
00603411121 ISOSORBIDE MONONITRATE ER
00832121700 JANTOVEN
00486111101 K-PHOS
00591060701 LABETALOL HCL
00173064255 LAMICTAL
65862022801 LAMOTRIGINE
60758006010 LEVOBUNOLOL HCL
00781518210 LEVOTHYROXINE SODIUM
00071015623 LIPITOR
68180098101 LISINOPRIL
68645055154 LISINOPRIL
76282042290 LISINOPRIL
00591086005 LISINOPRIL/HYDROCHLOROTHI
16571050111 LOSARTAN POTASSIUM
58657061110 LOSARTAN POTASSIUM
13668011630 LOSARTAN POTASSIUM/HYDROC
16714022401 LOSARTAN POTASSIUM/HYDROC
00185007001 LOVASTATIN
00185007401 LOVASTATIN
00555087204 MEDROXYPROGESTERONE ACETA
58657064050 METFORMIN HCL
65862000905 METFORMIN HCL
60505026001 METFORMIN HCL ER
16729003001 METHYLDOPA
57664022988 METHYLPHENIDATE HCL
00591271730 METHYLPHENIDATE HCL ER
49884082501 METOPROLOL SUCCINATE ER
55111046905 METOPROLOL SUCCINATE ER
00904634080 METOPROLOL TARTRATE
00904634180 METOPROLOL TARTRATE
00093873901 MEXILETINE HCL
53489038601 MINOXIDIL
65862056890 MONTELUKAST SODIUM
68180042201 MOXIFLOXACIN HCL
16729001901 MYCOPHENOLATE MOFETIL
00603762517 MYZILRA
00456340733 NAMENDA XR
52544024531 NECON 1/50-28
00093102406 NEFAZODONE HCL
68645051254 NIFEDIPINE ER
00093081201 NORTRIPTYLINE HCL
51672400302 NORTRIPTYLINE HCL
00169185189 NOVOFINE 32GX6MM
00472016315 NYSTATIN
17478071311 OFLOXACIN
24208041005 OFLOXACIN
52544084828 OGESTREL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
53 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
60505014601 OMEPRAZOLE
62175013637 OMEPRAZOLE
62175013643 OMEPRAZOLE
68462015813 ONDANSETRON ODT
67386031401 ONFI
00310610530 ONGLYZA
51991029301 OXCARBAZEPINE
50111045601 OXYBUTYNIN CHLORIDE
00054039063 OXYCODONE HCL
47781019605 OXYCODONE/ACETAMINOPHEN
10572010001 PEG-3350/ELECTROLYTES
51293081101 PHENAZOPYRIDINE HCL
00228280111 PILOCARPINE HYDROCHLORIDE
33342005407 PIOGLITAZONE HCL
33342005607 PIOGLITAZONE HCL
68001023500 POTASSIUM CHLORIDE ER
68001023508 POTASSIUM CHLORIDE ER
13668018490 PRAMIPEXOLE DIHYDROCHLORI
68382019616 PRAMIPEXOLE DIHYDROCHLORI
68462019890 PRAVASTATIN SODIUM
00143973801 PREDNISONE
00245003660 PREVALITE
00603544821 PROPAFENONE HCL
00228278111 PROPRANOLOL HCL ER
50242010040 PULMOZYME
68382065906 PYRIDOSTIGMINE BROMIDE
62175030246 RABEPRAZOLE SODIUM
52544015219 RAPAFLO
44087334401 REBIF REBIDOSE
00049233045 RELPAX
00378350591 RISPERIDONE
43547027310 ROPINIROLE HCL
62332003431 ROPINIROLE HCL
68462025701 ROPINIROLE HCL
57237017099 ROSUVASTATIN CALCIUM
16714061201 SERTRALINE HCL
69097083312 SERTRALINE HCL
00093715610 SIMVASTATIN
16714068102 SIMVASTATIN
16714068202 SIMVASTATIN
16729000717 SIMVASTATIN
31722051110 SIMVASTATIN
60505022201 SOTALOL HCL (AF)
53746051110 SPIRONOLACTONE
12496121203 SUBOXONE
00591078001 SUCRALFATE
00591079601 SULFASALAZINE
00378563259 SUMATRIPTAN SUCCINATE
55111029136 SUMATRIPTAN SUCCINATE
00228299611 TAMSULOSIN HCL
00378505001 TEMAZEPAM
67877014701 TEMAZEPAM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
54 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
61314022610 TIMOLOL MALEATE
24090049284 TIROSINT
24090049384 TIROSINT
68382013914 TOPIRAMATE
69097081803 TOPIRAMATE
50111044102 TRAZODONE HCL
51672128402 TRIAMCINOLONE ACETONIDE
00591034801 TRIAMTERENE/HYDROCHLOROTH
51862051006 TRIVORA-28
00591363630 TROSPIUM CHLORIDE ER
68012030930 UCERIS
64764067730 ULORIC
42806050301 URSODIOL
49884041301 URSODIOL
59746032430 VALACYCLOVIR HCL
43547037009 VALSARTAN
65862055190 VALSARTAN/HYDROCHLOROTHIA
65862052890 VENLAFAXINE HCL ER
65862069705 VENLAFAXINE HCL ER
68382003610 VENLAFAXINE HCL ER
00093304501 VERAPAMIL HCL ER
00591288601 VERAPAMIL HCL SR
00131248035 VIMPAT
66582031231 VYTORIN
57237012499 WARFARIN SODIUM
00173013555 WELLBUTRIN SR
00187073090 WELLBUTRIN XL
68727010001 XYREM
60505253106 ZIPRASIDONE HCL
00115067250 ZOLMITRIPTAN
00781714219 ADAPALENE
00781106101 ALPRAZOLAM
63402071201 ALVESCO
68180075601 AMLODIPINE BESYLATE/BENAZ
57237002901 AMOXICILLIN
00781187431 AMOXICILLIN/CLAVULANATE P
00781613954 AMOXICILLIN/CLAVULANATE P
00228306111 AMPHETAMINE/DEXTROAMPHETA
64980037603 ATOMOXETINE
50111078710 AZITHROMYCIN
59762314001 AZITHROMYCIN
00832102410 BACLOFEN
67877010605 BENZONATATE
45963014190 BUPROPION HCL XL
00143178701 BUTALBITAL/ACETAMINOPHEN/
00527131201 BUTALBITAL/ASPIRIN/CAFFEI
00456140530 BYSTOLIC
67253001106 CEFDINIR
65162005403 CITALOPRAM HYDROBROMIDE
00591350904 CLONIDINE HCL
55111019605 CLOPIDOGREL
68645051790 CYCLOBENZAPRINE HCL
00713066115 DESONIDE
68382010601 DIVALPROEX SODIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
55 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00527133601 DOXYCYCLINE HYCLATE
60505299506 DULOXETINE HCL
66993066260 DULOXETINE HCL
68180029706 DULOXETINE HCL
13668013605 ESCITALOPRAM OXALATE
13668015530 ESOMEPRAZOLE MAGNESIUM
00037043001 FELBATOL
00713032460 FLUOCINOLONE ACETONIDE
51672127304 FLUOCINONIDE
51862049430 FLUOCINONIDE
51862049460 FLUOCINONIDE
60758088010 FLUOROMETHOLONE
00378041401 FLUVOXAMINE MALEATE
60505016601 FLUVOXAMINE MALEATE
62559016001 FLUVOXAMINE MALEATE
00603373932 FUROSEMIDE
00591084401 GLIPIZIDE ER
00378106301 GUANFACINE ER
42192034001 HYOSCYAMINE SULFATE
51672414506 IMIQUIMOD
76204060060 IPRATROPIUM BROMIDE/ALBUT
00093823898 IRBESARTAN/HYDROCHLOROTHI
66758017092 KLOR-CON M10
16714037304 LAMOTRIGINE
00378803077 LANSOPRAZOLE
55111028130 LEVOFLOXACIN
00456202001 LEXAPRO
00378277701 LORAZEPAM
00781537705 LORAZEPAM
68180022907 MEMANTINE HCL
00054458111 MERCAPTOPURINE
57664047458 METFORMIN HCL
00406575501 METHADONE HCL
00093220301 METOCLOPRAMIDE HCL
00168038360 METRONIDAZOLE
00713063737 METRONIDAZOLE
13668048201 MINOCYCLINE HCL
00591111710 MIRTAZAPINE
60505252703 MODAFINIL
61748030413 MYORISAN
00185014601 NABUMETONE
00536110688 NICOTINE TRANSDERMAL SYST
00536589588 NICOTINE TRANSDERMAL SYST
00009540001 NICOTROL INHALER
62175026237 NIFEDIPINE ER
00074333330 NORVIR
00781223410 OMEPRAZOLE
45963053930 ONDANSETRON HCL
00378773493 ONDANSETRON ODT
68462013701 OXCARBAZEPINE
00093520801 OXYBUTYNIN CHLORIDE ER
64980021101 OXYBUTYNIN CHLORIDE ER
64720022410 OXYCODONE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
56 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
65162004810 OXYCODONE HCL
31722019201 OXYCODONE/ACETAMINOPHEN
54458099010 PAROXETINE HCL
60505003306 PENTOXIFYLLINE ER
00245007111 POTASSIUM CITRATE ER
68180048709 PRAVASTATIN SODIUM
00603533932 PREDNISONE
69315030230 PROCTO-MED HC
27241000406 RISPERIDONE
65862060012 RIZATRIPTAN BENZOATE
51991036378 RIZATRIPTAN BENZOATE ODT
43547027210 ROPINIROLE HCL
60505450209 ROSUVASTATIN CALCIUM
69097083502 SERTRALINE HCL
59762003301 SILDENAFIL
53746051405 SPIRONOLACTONE
00378014101 SPIRONOLACTONE/HYDROCHLOR
00591566001 SULINDAC
00781207601 TAMSULOSIN HCL
67405050010 TERBINAFINE HCL
57237014001 TORSEMIDE
00065026005 TRAVATAN Z
66530025420 TRETINOIN
00173093308 VALTREX
68180016613 VANCOMYCIN HCL
51672403501 WARFARIN SODIUM
68001024200 ZONISAMIDE
68462013001 ZONISAMIDE
00378400701 ALPRAZOLAM
00781148601 AMITRIPTYLINE HCL
00093716755 AMLODIPINE BESYLATE
00603210802 AMLODIPINE BESYLATE
67877019790 AMLODIPINE BESYLATE
67253015050 AMOXICILLIN
00781613957 AMOXICILLIN/CLAVULANATE P
00185084201 AMPHETAMINE/DEXTROAMPHETA
00378206301 ATENOLOL/CHLORTHALIDONE
66993006272 ATOVAQUONE
68462050201 AZATHIOPRINE
16714007104 BACLOFEN
00168005646 BETAMETHASONE DIPROPIONAT
00713080753 BETAMETHASONE DIPROPIONAT
00781751587 BUDESONIDE
00378043301 BUPROPION HCL
62332014131 CELECOXIB
00185093997 CHOLESTYRAMINE LIGHT
16714065204 CIPROFLOXACIN HCL
17478071410 CIPROFLOXACIN HCL
00168020230 CLINDAMYCIN PHOSPHATE
51672125801 CLOBETASOL PROPIONATE
51672125902 CLOBETASOL PROPIONATE
29300013501 CLONIDINE HCL
61314023710 CROMOLYN SODIUM
69918010101 DESMOPRESSIN ACETATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
57 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
64764017530 DEXILANT
00378247401 DICLOFENAC POTASSIUM
00591079501 DICYCLOMINE HCL
00071036932 DILANTIN
00378534005 DILTIAZEM HCL ER
62756079688 DIVALPROEX SODIUM DR
68382003305 DIVALPROEX SODIUM DR
55111053405 DIVALPROEX SODIUM ER
00093206901 DOXAZOSIN MESYLATE
68180065001 DOXYCYCLINE MONOHYDRATE
13668011030 DULOXETINE HCL
57237001830 DULOXETINE HCL
68180029407 DULOXETINE HCL
68382092386 ELETRIPTAN HYDROBROMIDE
00781322464 ENOXAPARIN SODIUM
24338011013 ERYTHROMYCIN ETHYLSUCCINA
16729016801 ESCITALOPRAM OXALATE
68001019700 ESCITALOPRAM OXALATE
00115053301 FENOFIBRATE MICRONIZED
70461000201 FLUAD 2017-2018
57237000430 FLUCONAZOLE
65162070294 FLUOCINOLONE ACETONIDE
16714035101 FLUOXETINE HCL
00781181801 FUROSEMIDE
10370019101 GLIPIZIDE ER
64980027903 GLIPIZIDE ER
90166083152 GLOBAL EASE INJECT PEN NE
00168008016 HYDROCORTISONE
00378014701 INDOMETHACIN
42799080601 IVERMECTIN
00597015330 JARDIANCE
60505100301 KETOROLAC TROMETHAMINE
61314012610 KETOROLAC TROMETHAMINE
59746024501 LAMOTRIGINE
59746024760 LAMOTRIGINE
59746024860 LAMOTRIGINE
16729003415 LETROZOLE
68382001701 LEVOFLOXACIN
00185060501 LISINOPRIL
16729038017 LISINOPRIL
00185015210 LISINOPRIL/HYDROCHLOROTHI
00781537105 LORAZEPAM
00093736498 LOSARTAN POTASSIUM
68180021003 LOSARTAN POTASSIUM
00781520431 LOSARTAN POTASSIUM/HYDROC
53746017360 MEMANTINE HCL
60505132901 METFORMIN HCL ER
67877011601 METHADONE HCL
31722053305 METHOCARBAMOL
62175015237 METHYLPHENIDATE HCL CD
00406015401 METHYLPHENIDATE HCL ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
58 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
62332011391 METOPROLOL TARTRATE
00168032346 METRONIDAZOLE
66993096245 METRONIDAZOLE
00378190101 MIDODRINE HCL
57237001030 MIRTAZAPINE
00713063437 MOMETASONE FUROATE
24208063562 NEOMYCIN/POLYMYXIN/HYDROC
50474080303 NEUPRO
51672400205 NORTRIPTYLINE HCL
45802004811 NYSTATIN
24208041010 OFLOXACIN
61314027225 OLOPATADINE HYDROCHLORIDE
00378521193 OMEPRAZOLE
45963053830 ONDANSETRON HCL
00781523964 ONDANSETRON ODT
70710101002 OSELTAMIVIR PHOSPHATE
62756018588 OXCARBAZEPINE
10702005701 OXYCODONE HCL
59746028390 PANTOPRAZOLE SODIUM
16714023501 PENICILLIN V POTASSIUM
16729002115 PIOGLITAZONE HCL
59762014501 PIROXICAM
13668009390 PRAMIPEXOLE DIHYDROCHLORI
13668009490 PRAMIPEXOLE DIHYDROCHLORI
55111023005 PRAVASTATIN SODIUM
60758011915 PREDNISOLONE ACETATE
00603533732 PREDNISONE
43598034901 PROGESTERONE
67253065110 PROPYLTHIOURACIL
59148003913 REXULTI
69097086685 RIZATRIPTAN BENZOATE
57237008663 RIZATRIPTAN BENZOATE ODT
43547027410 ROPINIROLE HCL
68462025401 ROPINIROLE HCL
50484001030 SANTYL
16714061101 SERTRALINE HCL
16714061304 SERTRALINE HCL
00006911731 SINGULAIR
42582060023 SODIUM SULFACETAMIDE/SULF
53489014305 SPIRONOLACTONE
59762010401 SULFASALAZINE
00781317307 SUMATRIPTAN SUCCINATE REF
00186037220 SYMBICORT
00187149605 TIMOPTIC OCUDOSE
13668019090 TOLTERODINE TARTRATE ER
00069024430 TOVIAZ
68180069706 TRAMADOL HCL ER
67877025130 TRIAMCINOLONE ACETONIDE
00310080060 TUDORZA PRESSAIR
65862057290 VALSARTAN
00093304301 VERAPAMIL HCL ER
00078036542 VIVELLE-DOT
00093172001 WARFARIN SODIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
59 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
57237011901 WARFARIN SODIUM
00069100101 XELJANZ
00378531001 ZOLPIDEM TARTRATE
00228348111 ZOLPIDEM TARTRATE ER
00781531501 ZOLPIDEM TARTRATE ER
51672402301 ACETAZOLAMIDE
00378702393 ACITRETIN
00378699252 ALBUTEROL SULFATE
00378827055 ALBUTEROL SULFATE
00093517144 ALENDRONATE SODIUM
16729013401 ALLOPURINOL
67253090110 ALPRAZOLAM
00574029201 AMILORIDE HCL
16729017201 AMITRIPTYLINE HCL
16729017301 AMITRIPTYLINE HCL
29300024210 AMLODIPINE BESYLATE
00093737201 AMLODIPINE BESYLATE/BENAZ
00378689801 AMLODIPINE BESYLATE/BENAZ
66685100101 AMOXICILLIN/CLAVULANATE P
66993059602 AMPHETAMINE/DEXTROAMPHETA
00093756956 ARIPIPRAZOLE
43598055630 ARIPIPRAZOLE
60505307503 ARIPIPRAZOLE
00093309256 ARMODAFINIL
00378343293 ARMODAFINIL
65162059606 ASPIRIN/DIPYRIDAMOLE
00378075701 ATENOLOL
63304062210 ATENOLOL
00378395005 ATORVASTATIN CALCIUM
62175089143 ATORVASTATIN CALCIUM
59762312001 AZITHROMYCIN
43547033710 BENAZEPRIL HCL
60505015701 BUPROPION HCL
69097087803 BUPROPION HCL SR
64380074207 BUSPIRONE HCL
68382018201 BUSPIRONE HCL
49884065809 CANDESARTAN CILEXETIL
49884066009 CANDESARTAN CILEXETIL
66993040832 CARBAMAZEPINE ER
62756051888 CARBIDOPA/LEVODOPA
76385011350 CARVEDILOL
51862023803 CAZIANT
68180072220 CEFDINIR
00093107853 CEFPROZIL
65862070060 CEFUROXIME AXETIL
00093417774 CEPHALEXIN
00069046856 CHANTIX
00054002821 CILOSTAZOL
00143992701 CIPROFLOXACIN HCL
54458088916 CITALOPRAM HYDROBROMIDE
61748020160 CLINDAMYCIN PHOSPHATE
00472040030 CLOBETASOL PROPIONATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
60 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00228300311 CLONAZEPAM
16714047101 CLONAZEPAM
29300013701 CLONIDINE HCL
00378362777 CLOPIDOGREL
60505025303 CLOPIDOGREL
00032121207 CREON
63323004401 CYANOCOBALAMIN
00603752149 CYCLAFEM 1/35
45802042335 DESONIDE
00228255111 DICLOFENAC SODIUM DR
00093312501 DICLOXACILLIN SODIUM
49884083005 DILTIAZEM CD
00378052501 DILTIAZEM HCL
10370082909 DILTIAZEM HCL ER
00555028602 DIPYRIDAMOLE
68382003205 DIVALPROEX SODIUM DR
55111053305 DIVALPROEX SODIUM ER
53489064701 DOXYCYCLINE HYCLATE
00228289296 DULOXETINE HCL
13668011005 DULOXETINE HCL
60505387709 DUTASTERIDE
66993058030 DUTASTERIDE/TAMSULOSIN HC
45802046611 ECONAZOLE NITRATE
45802046653 ECONAZOLE NITRATE
16714044301 ENALAPRIL MALEATE
00955101210 ENOXAPARIN SODIUM
49502010102 EPINEPHRINE
54458089116 ESCITALOPRAM OXALATE
68645051954 ESCITALOPRAM OXALATE
43598051030 ESOMEPRAZOLE MAGNESIUM
00093322308 ESTRADIOL
00378336099 ESTRADIOL
00781716783 ESTRADIOL
51862033201 ESTRADIOL
00378527101 ESZOPICLONE
45963056808 EZETIMIBE/SIMVASTATIN
00093775598 FENOFIBRATE
68180036209 FENOFIBRATE
69097045905 FENOFIBRATE
57237006205 FINASTERIDE
62559038201 FLECAINIDE ACETATE
65162064210 FLECAINIDE ACETATE
68462010340 FLUCONAZOLE
51672126402 FLUOCINONIDE
00054829925 FUROSEMIDE
00603374032 FUROSEMIDE
16714050502 GABAPENTIN
67877022205 GABAPENTIN
69097081507 GABAPENTIN
00093542328 GIANVI
68001017700 GLIMEPIRIDE
60505014100 GLIPIZIDE
65862008201 GLYBURIDE/METFORMIN HCL
49884006601 GLYCOPYRROLATE
00228285511 GUANFACINE ER
65162071310 GUANFACINE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
61 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00603385632 HYDROCHLOROTHIAZIDE
13107001901 HYDROCODONE/ACETAMINOPHEN
23155050001 HYDROXYZINE HCL
55111057503 IBANDRONATE SODIUM
67877032105 IBUPROFEN
68645053059 IBUPROFEN
00781176401 IMIPRAMINE HCL
00173087310 INCRUSE ELLIPTA
00487020160 IPRATROPIUM BROMIDE/ALBUT
43547033009 IRBESARTAN/HYDROCHLOROTHI
00603411221 ISOSORBIDE MONONITRATE ER
00832121610 JANTOVEN
00006057761 JANUMET
00006008061 JANUMET XR
00185001005 LABETALOL HCL
49884012301 LABETALOL HCL
69097015112 LAMOTRIGINE
55111071830 LAMOTRIGINE ER
45963046103 LANSOPRAZOLE
00555901467 LESSINA
31722053960 LEVETIRACETAM
00173083113 LEVITRA
24208050510 LEVOBUNOLOL HCL
50383017104 LEVOCARNITINE
00591040710 LISINOPRIL
00603421221 LISINOPRIL
68001027108 LISINOPRIL
00054252725 LITHIUM CARBONATE
66869020490 LIVALO
31722070110 LOSARTAN POTASSIUM
68645040770 LOSARTAN POTASSIUM
00781520692 LOSARTAN POTASSIUM/HYDROC
16714022602 LOSARTAN POTASSIUM/HYDROC
00093092806 LOVASTATIN
00185007460 LOVASTATIN
52544084728 LOW-OGESTREL
00093726701 METFORMIN HCL ER
00054455015 METHOTREXATE
57664023088 METHYLPHENIDATE HCL
00093529701 METHYLPHENIDATE HCL CD
45963020011 METHYLPHENIDATE HCL ER
00115165102 METOCLOPRAMIDE HCL
57237010199 METOPROLOL TARTRATE
57664016658 METOPROLOL TARTRATE
57664047752 METOPROLOL TARTRATE
52544024928 MICROGESTIN FE
68382031818 MINOCYCLINE HCL
65862060201 MODAFINIL
00713063415 MOMETASONE FUROATE
00093742556 MONTELUKAST SODIUM
52343003790 MONTELUKAST SODIUM
68462056417 MUPIROCIN
00093081901 NIFEDICAL XL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
62 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68682010910 NIFEDIPINE ER
51672400105 NORTRIPTYLINE HCL
51672400401 NORTRIPTYLINE HCL
00169185389 NOVOTWIST 32GX5MM
42543005262 NYSTATIN
00093510556 OLANZAPINE
00093576856 OLANZAPINE
00093577156 OLANZAPINE
00299382230 ORACEA
65162037310 OXYBUTYNIN CHLORIDE ER
13107004501 OXYCODONE/ACETAMINOPHEN
65862056099 PANTOPRAZOLE SODIUM
68645049270 PANTOPRAZOLE SODIUM
00378700393 PAROXETINE HCL
13107015490 PAROXETINE HCL
13107015690 PAROXETINE HCL
43547034811 PAROXETINE HCL
62175044601 PEG 3350/ELECTROLYTES
51293062601 PHENOBARBITAL
16729002015 PIOGLITAZONE HCL
16729002215 PIOGLITAZONE HCL
00781152610 POTASSIUM CHLORIDE CR
00574027505 POTASSIUM CHLORIDE ER
00781151601 POTASSIUM CHLORIDE SR
33342003310 PRAMIPEXOLE DIHYDROCHLORI
16252052750 PRAVASTATIN SODIUM
16252052990 PRAVASTATIN SODIUM
16729000916 PRAVASTATIN SODIUM
54458092716 PRAVASTATIN SODIUM
00008122201 PRISTIQ
00591534701 PROBENECID
65162052110 PROMETHAZINE HCL
00591555701 PROPRANOLOL HCL
16729015001 QUETIAPINE FUMARATE
43598050530 RALOXIFENE HYDROCHLORIDE
66993066130 RALOXIFENE HYDROCHLORIDE
59148003813 REXULTI
00527131501 RIFAMPIN
43547027110 ROPINIROLE HCL
62332003331 ROPINIROLE HCL
68462025601 ROPINIROLE HCL
16252061630 ROSUVASTATIN CALCIUM
16252061690 ROSUVASTATIN CALCIUM
00456152560 SAVELLA
00456155060 SAVELLA
00093715698 SIMVASTATIN
16729015615 SIMVASTATIN
31722051390 SIMVASTATIN
68382006616 SIMVASTATIN
59762100301 SIROLIMUS
00527181843 SUMATRIPTAN
62756052169 SUMATRIPTAN SUCCINATE
62756016088 TAMSULOSIN HCL
51672130406 TERCONAZOLE
00378520001 TOLMETIN SODIUM
59762080002 TOLTERODINE TARTRATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
63 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00069024230 TOVIAZ
57664037708 TRAMADOL HCL
00574222545 TRETINOIN
64980032005 TRIAMCINOLONE ACETONIDE D
00781100801 TRIAMTERENE/HYDROCHLOROTH
00781506701 TRIAMTERENE/HYDROCHLOROTH
59746032530 VALACYCLOVIR HCL
65862075360 VALGANCICLOVIR
43547036703 VALSARTAN
00378632177 VALSARTAN/HYDROCHLOROTHIA
00006484100 VAQTA
68382003510 VENLAFAXINE HCL ER
68382003616 VENLAFAXINE HCL ER
23155002601 VERAPAMIL HCL
00378218001 VERAPAMIL HCL ER
00078034642 VIVELLE-DOT
00093528956 VORICONAZOLE
52544098131 ZARAH
00955170310 ZOLPIDEM TARTRATE ER
68382026101 ACETAZOLAMIDE ER
69076014601 ACYCLOVIR
68462040355 ADAPALENE
00378500577 ALFUZOSIN HCL ER
24208035305 ALREX
55111034101 AMLODIPINE BESYLATE/BENAZ
00378661493 AMNESTEEM
64720013010 AMPHETAMINE/DEXTROAMPHETA
64720013610 AMPHETAMINE/DEXTROAMPHETA
00088250205 APIDRA SOLOSTAR
33342012307 ARIPIPRAZOLE
00093309356 ARMODAFINIL
00430078327 ASACOL HD
00904770480 ASPIR-LOW
00093354556 ATOMOXETINE
00603240621 BACLOFEN
67877010601 BENZONATATE
00168005546 BETAMETHASONE DIPROPIONAT
00093022056 BICALUTAMIDE
00591376730 BUDESONIDE
00781105301 BUPROPION HCL
00603254428 BUTALBITAL/ACETAMINOPHEN/
51862054001 BUTALBITAL/ACETAMINOPHEN/
62037059805 CARTIA XT
42043025267 CEFDINIR
65862021860 CEFDINIR
68180040401 CEFPROZIL
64980030401 CHLORTHALIDONE
16571041110 CIPROFLOXACIN HCL
65862000501 CITALOPRAM HYDROBROMIDE
16714075002 CLONAZEPAM
00310075430 CRESTOR
10702000601 CYCLOBENZAPRINE HCL
00093574065 CYCLOSPORINE MODIFIED
00054418625 DEXAMETHASONE
60432046608 DEXAMETHASONE
00378609001 DILTIAZEM HCL ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
64 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00078035934 DIOVAN
00378041501 DIPHENOXYLATE/ATROPINE
00008083622 EFFEXOR XR
00187510102 ELIDEL
00955100410 ENOXAPARIN SODIUM
00955100810 ENOXAPARIN SODIUM
49884022805 EZETIMIBE
65862085901 FAMOTIDINE
50419082901 FINACEA
65862062201 FLECAINIDE ACETATE
64980032920 FLUOCINOLONE ACETONIDE
60505011308 GABAPENTIN
69097081512 GABAPENTIN
45802004635 GENTAMICIN SULFATE
55111032201 GLIMEPIRIDE
00781145201 GLIPIZIDE
00378106501 GUANFACINE ER
00002882427 HUMULIN R U-500 KWIKPEN
68462035401 HYDROXYZINE HCL
00555030202 HYDROXYZINE PAMOATE
69238110105 IBUPROFEN
56151060150 KETOCARE
66758016001 KLOR-CON 10
00121057716 LACTULOSE
00603137858 LACTULOSE
69097015212 LAMOTRIGINE
63402030430 LATUDA
31722072150 LEVOFLOXACIN
00378361101 LIOTHYRONINE SODIUM
68462022301 LITHIUM CARBONATE ER
00006026718 MAXALT
69097015815 MELOXICAM
65862000901 METFORMIN HCL
64720040110 METHYLPHENIDATE HCL ER
00378190301 MIDODRINE HCL
00378557593 MODAFINIL
00456430001 MONUROL
00310197030 MOVANTIK
68462056435 MUPIROCIN
69547035302 NARCAN
24208079535 NEOMYCIN/POLYMYXIN/DEXAME
61314064610 NEOMYCIN/POLYMYXIN/HYDROC
50474080403 NEUPRO
00536589488 NICOTINE TRANSDERMAL SYST
00378048101 NIFEDIPINE ER
24979000901 NIFEDIPINE ER
65162047505 NORETHINDRONE ACETATE
42192033101 NP THYROID 90
33342007007 OLANZAPINE
68462023110 OMEPRAZOLE
54838055550 ONDANSETRON HCL
53885013610 ONETOUCH DELICA LANCETS E
00406052301 OXYCODONE/ACETAMINOPHEN
55111033390 PANTOPRAZOLE SODIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
65 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378200393 PAROXETINE HCL ER
00065427325 PAZEO
00781165510 PENICILLIN V POTASSIUM
55111023105 PRAVASTATIN SODIUM
00093406701 PRAZOSIN HCL
59746017106 PREDNISONE
00093535401 PROGESTERONE
00591555510 PROPRANOLOL HCL
67877024201 QUETIAPINE FUMARATE
59148003613 REXULTI
00527131530 RIFAMPIN
61748001860 RIFAMPIN
00597015561 STIOLTO RESPIMAT
50383082316 SULFAMETHOXAZOLE/TRIMETHO
55111029109 SUMATRIPTAN SUCCINATE
55111069312 SUMATRIPTAN SUCCINATE
51862044630 TAMOXIFEN CITRATE
00023915530 TAZORAC
00378340293 TOLTERODINE TARTRATE ER
69097012303 TOPIRAMATE
69097012403 TOPIRAMATE
00574220145 TRETINOIN
00574220545 TRETINOIN
43478024345 TRETINOIN
66530025745 TRETINOIN
00168000215 TRIAMCINOLONE ACETONIDE
00093725956 VALACYCLOVIR HCL
68382003516 VENLAFAXINE HCL ER
00093171210 WARFARIN SODIUM
00093171310 WARFARIN SODIUM
50458058030 XARELTO
00069050130 XELJANZ XR
51672402201 ACETAZOLAMIDE
00093630195 ADAPALENE
13668002101 ALFUZOSIN HCL ER
16714004210 ALLOPURINOL
69452014220 AMANTADINE HCL
51672405506 AMIODARONE HCL
00378267501 AMITRIPTYLINE HCL
00093008398 AMLODIPINE BESYLATE
67877019990 AMLODIPINE BESYLATE
51672130104 AMMONIUM LACTATE
57237003105 AMOXICILLIN
13668021630 ARIPIPRAZOLE
00378021801 ATENOLOL
00378023101 ATENOLOL
00093354656 ATOMOXETINE
68462026830 ATOMOXETINE
00172409660 BACLOFEN
51672127406 BETAMETHASONE DIPROPIONAT
00378715501 BUDESONIDE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
66 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68001032203 BUPROPION HCL XL
69097087602 BUPROPION HCL XL
00527169501 BUTALBITAL/ACETAMINOPHEN/
49884016111 CALCITONIN SALMON
00228254010 CARBIDOPA/LEVODOPA
68180030360 CEFUROXIME AXETIL
00002446330 CIALIS
16571041210 CIPROFLOXACIN HCL
55111012705 CIPROFLOXACIN HCL
00713065631 CLOBETASOL PROPIONATE
51672125803 CLOBETASOL PROPIONATE
00093083205 CLONAZEPAM
00093731405 CLOPIDOGREL
00591565810 CYCLOBENZAPRINE HCL
52817019010 CYCLOBENZAPRINE HCL
64980030550 DENTA 5000 PLUS
00713066160 DESONIDE
00781268901 DEXMETHYLPHENIDATE HCL ER
00378027101 DIAZEPAM
61442010301 DICLOFENAC SODIUM DR
00527058601 DICYCLOMINE HCL
00527132410 DIGOX
29300013801 DIVALPROEX SODIUM DR
43547027503 DONEPEZIL HCL
00378425001 DOXEPIN HCL
57237001760 DULOXETINE HCL
00093831118 ELETRIPTAN HYDROBROMIDE
00548560200 ENOXAPARIN SODIUM
00078065920 ENTRESTO
13668013710 ESCITALOPRAM OXALATE
16729016917 ESCITALOPRAM OXALATE
31722025090 ESCITALOPRAM OXALATE
00115051101 FENOFIBRATE MICRONIZED
00378911998 FENTANYL
00406907576 FENTANYL
00591319872 FENTANYL
64980033004 FLUOCINOLONE ACETONIDE SC
51672127902 FLUOCINONIDE
00093360782 FLUTICASONE PROPIONATE/SA
45963055611 GABAPENTIN
68462012701 GABAPENTIN
68180043501 GATIFLOXACIN
00228285011 GUANFACINE ER
00228285111 GUANFACINE ER
10370053801 GUANFACINE ER
68645051001 HYDROCHLOROTHIAZIDE
45802000403 HYDROCORTISONE
00713066860 HYDROCORTISONE VALERATE
13107010801 HYDROMORPHONE HCL
00555088202 HYDROXYUREA
23155050201 HYDROXYZINE HCL
00591080101 HYDROXYZINE PAMOATE
50458014090 INVOKANA
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
67 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00006027731 JANUVIA
16714070001 LAMOTRIGINE
29300011416 LAMOTRIGINE
55111039905 LANSOPRAZOLE
31722053705 LEVETIRACETAM
68462034690 LEVOCETIRIZINE DIHYDROCHL
51672302002 LIDOCAINE
00185540001 LISINOPRIL
00603421228 LISINOPRIL
68645055054 LISINOPRIL
29300012510 MELOXICAM
00378718605 METFORMIN HCL
42806031305 METFORMIN HCL
13107008801 METHADONE HCL
00185021001 METHIMAZOLE
13811070910 METHYLPHENIDATE HCL ER
00093220305 METOCLOPRAMIDE HCL
00121057616 METOCLOPRAMIDE HCL
51672416403 METRONIDAZOLE
13107000105 MIRTAZAPINE
13107003234 MIRTAZAPINE
62332010630 MODAFINIL
27241001890 MONTELUKAST SODIUM
54458089010 MONTELUKAST SODIUM
68645052801 MONTELUKAST SODIUM
00591367001 NABUMETONE
00093117701 NEOMYCIN SULFATE
00093739298 NIACIN ER
47781030801 NITROFURANTOIN MACROCRYST
00472016615 NYSTATIN
51672128902 NYSTATIN
55111016730 OLANZAPINE
60505311103 OLANZAPINE
55111015905 OMEPRAZOLE
65862018830 ONDANSETRON HCL
69238126601 OSELTAMIVIR PHOSPHATE
62756018413 OXCARBAZEPINE
16729031901 OXYBUTYNIN CHLORIDE ER
00406851501 OXYCODONE HCL
53746020305 OXYCODONE/ACETAMINOPHEN
13107015530 PAROXETINE HCL
68382009801 PAROXETINE HCL
00093117401 PENICILLIN V POTASSIUM
66993057630 PRASUGREL
16729000815 PRAVASTATIN SODIUM
61314063715 PREDNISOLONE ACETATE
43598035001 PROGESTERONE
00378018310 PROPRANOLOL HCL
00378018505 PROPRANOLOL HCL
00603548332 PROPRANOLOL HCL
23155011001 PROPRANOLOL HCL
50111046901 PROPRANOLOL HCL
00093206301 QUETIAPINE FUMARATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
68 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
43547034150 RISPERIDONE
47781030403 RIVASTIGMINE TRANSDERMAL
33342008750 RIZATRIPTAN BENZOATE
68462046806 RIZATRIPTAN BENZOATE ODT
45802058084 SCOPOLAMINE
57894007002 SIMPONI
65862005090 SIMVASTATIN
59762100101 SIROLIMUS
59746021605 SPIRONOLACTONE
50458029515 SPORANOX
00781930201 TACROLIMUS
00904640180 TAMSULOSIN HCL
62756016013 TAMSULOSIN HCL
51672130200 TERCONAZOLE
00591322126 TESTOSTERONE ENANTHATE
47335070713 TOPIRAMATE
00169255013 TRESIBA FLEXTOUCH
67877025115 TRIAMCINOLONE ACETONIDE
51660014030 VALSARTAN
00093738101 VENLAFAXINE HCL
62332001131 VENLAFAXINE HCL
65862069790 VENLAFAXINE HCL ER
68382003406 VENLAFAXINE HCL ER
68462026005 VERAPAMIL HCL ER
62756025802 ZONISAMIDE
65162003310 ACETAMINOPHEN/CODEINE PHO
00023367060 ACZONE
00078062051 AFINITOR
29300015501 ALFUZOSIN HCL ER
00228202950 ALPRAZOLAM
67253090111 ALPRAZOLAM
00603221421 AMITRIPTYLINE HCL
16729017117 AMITRIPTYLINE HCL
00093716798 AMLODIPINE BESYLATE
00093716898 AMLODIPINE BESYLATE
67877019810 AMLODIPINE BESYLATE
76282023910 AMLODIPINE BESYLATE
00093226801 AMOXICILLIN
16714029401 AMOXICILLIN/CLAVULANATE P
16714047802 AMOXICILLIN/CLAVULANATE P
66685101201 AMOXICILLIN/CLAVULANATE P
00781214501 AMPICILLIN
00536100441 ASPIRIN
00054057521 ASPIRIN/DIPYRIDAMOLE
00093304006 ASPIRIN/DIPYRIDAMOLE
00093354756 ATOMOXETINE
00781538892 ATORVASTATIN CALCIUM
55111012305 ATORVASTATIN CALCIUM
68645045970 ATORVASTATIN CALCIUM
68645048254 ATORVASTATIN CALCIUM
69097089705 ATORVASTATIN CALCIUM
69097091112 ATORVASTATIN CALCIUM
00168026730 AUGMENTED BETAMETHASONE D
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
69 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68462029052 AUGMENTED BETAMETHASONE D
50111078867 AZITHROMYCIN
65162053750 BENZONATATE
00168005515 BETAMETHASONE DIPROPIONAT
00472038045 BETAMETHASONE DIPROPIONAT
16729002310 BICALUTAMIDE
29300018801 BISOPROLOL FUMARATE/HYDRO
00093744501 BUDESONIDE
45963014230 BUPROPION HCL XL
45963014290 BUPROPION HCL XL
16729020301 BUSPIRONE HCL
16729020312 BUSPIRONE HCL
68382018101 BUSPIRONE HCL
00713031853 CALCIPOTRIENE
00093065701 CALCITRIOL
00093735301 CALCITRIOL
29033002602 CALCIUM ACETATE
16729007329 CAPECITABINE
00093729601 CARVEDILOL
65862014501 CARVEDILOL
68462016501 CARVEDILOL
76385011250 CARVEDILOL
16714039301 CEFDINIR
16714039501 CEFPODOXIME PROXETIL
57237005960 CEFUROXIME AXETIL
00054033425 CEVIMELINE HCL
16571065710 CEVIMELINE HCL
00185094097 CHOLESTYRAMINE
49884046566 CHOLESTYRAMINE
16714065301 CIPROFLOXACIN HCL
13668000905 CITALOPRAM HYDROBROMIDE
54458098112 CITALOPRAM HYDROBROMIDE
45802056202 CLINDAMYCIN PHOSPHATE
51672401105 CLOMIPRAMINE HCL
00781556705 CLONAZEPAM
16714047002 CLONAZEPAM
55111019690 CLOPIDOGREL
00378003001 CLORAZEPATE DIPOTASSIUM
00574010714 CLOTRIMAZOLE
00023921115 COMBIGAN
68968051408 COMBIPATCH
17478060510 COSOPT
17478060430 COSOPT PF
00032122401 CREON
10702000750 CYCLOBENZAPRINE HCL
00093574265 CYCLOSPORINE MODIFIED
16714034804 DASETTA 1/35
00781197301 DESIPRAMINE HCL
59762121103 DESVENLAFAXINE ER
49884008701 DEXAMETHASONE
24208072002 DEXAMETHASONE SODIUM PHOS
00172392670 DIAZEPAM
00172392770 DIAZEPAM
59762002901 DICLOFENAC SODIUM/MISOPRO
00591079401 DICYCLOMINE HCL
49884083209 DILTIAZEM CD
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
70 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
10370083209 DILTIAZEM HCL ER
24658017190 DILTIAZEM HCL ER
68682037090 DILTIAZEM HCL ER
00078036034 DIOVAN
64980013501 DIPYRIDAMOLE
68382003301 DIVALPROEX SODIUM DR
00115691101 DIVALPROEX SODIUM ER
00115692202 DIVALPROEX SODIUM ER
16714048502 DIVALPROEX SODIUM ER
65162075550 DIVALPROEX SODIUM ER
00115143810 DUTASTERIDE
31722013130 DUTASTERIDE
00008083621 EFFEXOR XR
00378105405 ENALAPRIL MALEATE
68682071101 ENALAPRIL MALEATE
00703858023 ENOXAPARIN SODIUM
00781361268 ENOXAPARIN SODIUM
00955101010 ENOXAPARIN SODIUM
00955101510 ENOXAPARIN SODIUM
62037084920 ENOXAPARIN SODIUM
00115169549 EPINEPHRINE
49502050002 EPIPEN 2-PAK
13668013610 ESCITALOPRAM OXALATE
13668013705 ESCITALOPRAM OXALATE
54458089216 ESCITALOPRAM OXALATE
00093322397 ESTRADIOL
00555088704 ESTRADIOL
00378730753 ETHYNODIOL DIACETATE/ETHI
16714049902 ETODOLAC ER
00002416502 EVISTA
00115138708 EZETIMIBE/SIMVASTATIN
45963056608 EZETIMIBE/SIMVASTATIN
00378306677 FENOFIBRATE
00406900076 FENTANYL
31722052530 FINASTERIDE
65862062301 FLECAINIDE ACETATE
67405060301 FLUCONAZOLE
00093026492 FLUOCINONIDE
42543072701 FLUOXETINE HCL
50111064702 FLUOXETINE HCL
70461011910 FLUVIRIN 2016-2017
49281040188 FLUZONE HIGH-DOSE PF 2017
00781144601 FUROSEMIDE
68462012601 GABAPENTIN
63323001002 GENTAMICIN SULFATE
54458096616 GLIMEPIRIDE
68645015054 GLIPIZIDE
10370019001 GLIPIZIDE ER
00093745601 GLIPIZIDE/METFORMIN HCL
10370053401 GUANFACINE ER
00002850101 HUMULIN R U-500 (CONCENTR
23155000101 HYDRALAZINE HCL
68645051170 HYDROCHLOROTHIAZIDE
64376064016 HYDROCODONE BITARTRATE/AC
45802001405 HYDROCORTISONE
00713066915 HYDROCORTISONE VALERATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
71 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
43199001101 HYOSCYAMINE SULFATE
00065175007 ILEVRO
31722073090 IRBESARTAN
33342004810 IRBESARTAN
43547027703 IRBESARTAN
43547027809 IRBESARTAN
43547027903 IRBESARTAN
43547027909 IRBESARTAN
43547037603 IRBESARTAN
43547033103 IRBESARTAN/HYDROCHLOROTHI
00555007102 ISONIAZID
00603411028 ISOSORBIDE MONONITRATE ER
23155051901 ISOSORBIDE MONONITRATE ER
00093312242 JINTELI
51167020001 KALYDECO
00713067115 KETOCONAZOLE
00378113401 KETOROLAC TROMETHAMINE
50383077916 LACTULOSE
00093013201 LAMOTRIGINE
16714070201 LAMOTRIGINE
29300011316 LAMOTRIGINE
00781214892 LANSOPRAZOLE
63402030630 LATUDA
00955173730 LEFLUNOMIDE
13811067730 LEFLUNOMIDE
43547022315 LEVETIRACETAM
00378181501 LEVOTHYROXINE SODIUM
00527134101 LEVOTHYROXINE SODIUM
00527135201 LEVOTHYROXINE SODIUM
00781518410 LEVOTHYROXINE SODIUM
00781518710 LEVOTHYROXINE SODIUM
00781519092 LEVOTHYROXINE SODIUM
00378207410 LISINOPRIL
00378207605 LISINOPRIL
68001026808 LISINOPRIL
68180098001 LISINOPRIL
76282042245 LISINOPRIL
13668011510 LOSARTAN POTASSIUM
16571050211 LOSARTAN POTASSIUM
43547036211 LOSARTAN POTASSIUM
68180021103 LOSARTAN POTASSIUM
00781520492 LOSARTAN POTASSIUM/HYDROC
00781520710 LOSARTAN POTASSIUM/HYDROC
33342005210 LOSARTAN POTASSIUM/HYDROC
62332005091 LOSARTAN POTASSIUM/HYDROC
65862047099 LOSARTAN POTASSIUM/HYDROC
00185007210 LOVASTATIN
54458084516 LOVASTATIN
54458091410 LOVASTATIN
54458091510 LOVASTATIN
68001022408 LOVASTATIN
68180046707 LOVASTATIN
68180046801 LOVASTATIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
72 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
29300012401 MELOXICAM
61442012610 MELOXICAM
65580059401 METADATE ER
23155010205 METFORMIN HCL
42806022105 METFORMIN HCL
60429011190 METFORMIN HCL
68382076005 METFORMIN HCL
00185020501 METHIMAZOLE
00603457721 METHYLPHENIDATE HCL
00406147301 METHYLPHENIDATE HCL ER
64720040310 METHYLPHENIDATE HCL ER
00591079021 METHYLPREDNISOLONE DOSE P
00185005501 METOLAZONE
68001012200 METOPROLOL SUCCINATE ER
57237010299 METOPROLOL TARTRATE
16714041702 METOPROLOL/HYDROCHLOROTHI
29300022701 METRONIDAZOLE
29300022705 METRONIDAZOLE
50111033301 METRONIDAZOLE
51672529503 METRONIDAZOLE
51862029201 MICROGESTIN FE 1.5/30
52544023328 MICROGESTIN FE 1.5/30
60505132001 MIDODRINE HCL
68382031601 MINOCYCLINE HCL
60505024808 MIRTAZAPINE
00591246915 MIRTAZAPINE ODT
55253080230 MODAFINIL
68462022517 MOMETASONE FUROATE
33342010207 MONTELUKAST SODIUM
33342010210 MONTELUKAST SODIUM
57237021230 MONTELUKAST SODIUM
69452010713 MONTELUKAST SODIUM
60505058204 MOXIFLOXACIN HCL
69097086907 NADOLOL
68462018905 NAPROXEN
52544055228 NECON 1/35
24208083060 NEOMYCIN/POLYMYXIN/DEXAME
68180022301 NIACIN ER
00536303023 NICOTINE POLACRILEX
59762330401 NITROGLYCERIN
68180087613 NORETHINDRONE
51672400101 NORTRIPTYLINE HCL
66689000816 NYSTATIN
00093576756 OLANZAPINE
43598016630 OLANZAPINE
55111016330 OLANZAPINE
00093761156 OLMESARTAN MEDOXOMIL
57664075683 OLMESARTAN MEDOXOMIL
60505014500 OMEPRAZOLE
53885027210 ONETOUCH VERIO TEST STRIP
68462013801 OXCARBAZEPINE
68462013901 OXCARBAZEPINE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
73 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00603499121 OXYCODONE HCL
65162020710 OXYCODONE/ACETAMINOPHEN
13107015430 PAROXETINE HCL
13107015730 PAROXETINE HCL
68382009806 PAROXETINE HCL
00093412774 PENICILLIN V POTASSIUM
60758090810 POLYMYXIN B SULFATE/TRIME
68001030300 POTASSIUM CHLORIDE ER
44523041501 POTASSIUM CITRATE ER
54458092510 PRAVASTATIN SODIUM
54458092712 PRAVASTATIN SODIUM
68180048602 PRAVASTATIN SODIUM
68462019590 PRAVASTATIN SODIUM
50383004248 PREDNISOLONE
00054474131 PREDNISONE
42937070518 PRENATAL PLUS IRON
00005197105 PREVNAR 13
53746054405 PRIMIDONE
00469061773 PROGRAF
68382004101 PROMETHAZINE HCL
00054372763 PROPRANOLOL HCL
00115166201 PROPRANOLOL HCL
23155011401 PROPRANOLOL HCL
43478090088 PROPRANOLOL HCL ER
00115140408 PYRIDOSTIGMINE BROMIDE ER
00093816201 QUETIAPINE FUMARATE
00093729056 RALOXIFENE HYDROCHLORIDE
69097082507 RALOXIFENE HYDROCHLORIDE
00591204454 RISEDRONATE SODIUM
60505309702 RISEDRONATE SODIUM
13668003505 RISPERIDONE
13668003805 RISPERIDONE
13668003905 RISPERIDONE
00093757098 ROSUVASTATIN CALCIUM
16252061790 ROSUVASTATIN CALCIUM
55513007430 SENSIPAR
52343002345 SIMVASTATIN
68382006805 SIMVASTATIN
68682001004 SODIUM SULFACETAMIDE
00228280311 SPIRONOLACTONE
46287000601 SPS
00002322830 STRATTERA
65862042001 SULFAMETHOXAZOLE/TRIMETHO
00074662419 SYNTHROID
00168041630 TACROLIMUS
45802070001 TACROLIMUS
16714071302 TAMSULOSIN HCL
65862059801 TAMSULOSIN HCL
00781269375 TEMOZOLOMIDE
51991052633 TERBINAFINE HCL
00591321630 TESTOSTERONE
00603783188 TESTOSTERONE
00093005801 TRAMADOL HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
74 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
51672126705 TRIAMCINOLONE ACETONIDE D
00378135205 TRIAMTERENE/HYDROCHLOROTH
00591042405 TRIAMTERENE/HYDROCHLOROTH
68001032700 TRIAMTERENE/HYDROCHLOROTH
68180083713 TRI-LO-MARZIA
57237004330 VALACYCLOVIR HCL
65862057190 VALSARTAN
00173056504 VALTREX
16714031201 VENLAFAXINE HCL
65862052899 VENLAFAXINE HCL ER
68382003506 VENLAFAXINE HCL ER
00591040401 VERAPAMIL HCL
00456111030 VIIBRYD
68180087513 VYFEMLA
66582031331 VYTORIN
66582031554 VYTORIN
57237012301 WARFARIN SODIUM
50458057910 XARELTO
13668000810 ZOLPIDEM TARTRATE
00472012645 ADAPALENE
00078056751 AFINITOR
27241004221 ALMOTRIPTAN
00591492001 AMANTADINE HCL
16714044701 AMITRIPTYLINE HCL
16714044802 AMITRIPTYLINE HCL
67877019890 AMLODIPINE BESYLATE
68382012105 AMLODIPINE BESYLATE
00093737301 AMLODIPINE BESYLATE/BENAZ
00143988750 AMOXICILLIN
00143988901 AMOXICILLIN
00143993905 AMOXICILLIN
00781506101 AMOXICILLIN
00378083194 AMOXICILLIN/CLAVULANATE P
00781610446 AMOXICILLIN/CLAVULANATE P
16714029402 AMOXICILLIN/CLAVULANATE P
43598022114 AMOXICILLIN/CLAVULANATE P
64720013510 AMPHETAMINE/DEXTROAMPHETA
33342012207 ARIPIPRAZOLE
43598055530 ARIPIPRAZOLE
60505267703 ARIPIPRAZOLE
00378343193 ARMODAFINIL
00085433401 ASMANEX HFA
51079068420 ATENOLOL
00781538292 ATORVASTATIN CALCIUM
68462040401 ATOVAQUONE/PROGUANIL HCL
00597008717 ATROVENT HFA
66993089715 AUGMENTED BETAMETHASONE D
69238107601 AZATHIOPRINE
00603243321 BENZTROPINE MESYLATE
00603243421 BENZTROPINE MESYLATE
00168005760 BETAMETHASONE DIPROPIONAT
00472038015 BETAMETHASONE DIPROPIONAT
50383024971 BROMFENAC
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
75 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
47781014601 BUDESONIDE
43547029009 BUPROPION HCL ER
00591354376 BUPROPION HCL SR
00093005405 BUSPIRONE HCL
16729020216 BUSPIRONE HCL
68382018305 BUSPIRONE HCL
00591321901 BUTALBITAL/ASPIRIN/CAFFEI
16714039201 CEFDINIR
57237009960 CEFDINIR
00781543920 CEFPODOXIME PROXETIL
65862009620 CEFPODOXIME PROXETIL
68180039601 CELECOXIB
00093314701 CEPHALEXIN
65862001901 CEPHALEXIN
00065853110 CIPRO HC
57237004560 CLARITHROMYCIN
65862022660 CLARITHROMYCIN
00472040045 CLOBETASOL PROPIONATE
00713065615 CLOBETASOL PROPIONATE
50383026760 CLOBETASOL PROPIONATE
00574010770 CLOTRIMAZOLE
00378077101 CYCLOBENZAPRINE HCL
00603307828 CYCLOBENZAPRINE HCL
00002324030 CYMBALTA
51672128101 DESONIDE
00054040113 DESVENLAFAXINE ER
63323016530 DEXAMETHASONE SODIUM PHOS
00093556201 DEXMETHYLPHENIDATE HCL ER
00054318863 DIAZEPAM
00228255196 DICLOFENAC SODIUM DR
00378414001 DISULFIRAM
00781224301 DIVALPROEX SODIUM
00378047305 DIVALPROEX SODIUM ER
65162075710 DIVALPROEX SODIUM ER
65162075750 DIVALPROEX SODIUM ER
13668011130 DULOXETINE HCL
58406043504 ENBREL
00703854023 ENOXAPARIN SODIUM
51991083675 EPINASTINE HCL
00574402435 ERYTHROMYCIN
55111061701 ESZOPICLONE
00093089201 ETODOLAC
00378912198 FENTANYL
00173060102 FLOVENT DISKUS
70461030110 FLUCELVAX QUADRIVALENT 20
55111014630 FLUCONAZOLE
00168005960 FLUOCINOLONE ACETONIDE
65162070486 FLUOCINOLONE ACETONIDE BO
65162070386 FLUOCINOLONE ACETONIDE SC
51672138603 FLUOCINONIDE
65862020001 GABAPENTIN
00093834401 GLYBURIDE
69076047601 GLYCOPYRROLATE
00378033401 HALOPERIDOL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
76 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00074433907 HUMIRA PEN-PSORIASIS STAR
00002821501 HUMULIN R
50111032703 HYDRALAZINE HCL
27808003703 HYDROCODONE/ACETAMINOPHEN
65162011510 HYDROCODONE/ACETAMINOPHEN
45802047264 HYDROCORTISONE ACETATE/PR
51672129006 HYDROCORTISONE VALERATE
00527135301 HYDROMORPHONE HCL
16714008110 HYDROXYZINE HCL
68462035201 HYDROXYZINE HCL
00185061501 HYDROXYZINE PAMOATE
67877032005 IBUPROFEN
00168043224 IMIQUIMOD
00378014301 INDOMETHACIN
68462040601 INDOMETHACIN
00168009915 KETOCONAZOLE
00781709004 KETOCONAZOLE
16714037202 LAMOTRIGINE
23155004403 LEFLUNOMIDE
62756051183 LETROZOLE
00781400332 LEUPROLIDE ACETATE
33342002332 LEVOFLOXACIN
68180024201 LEVOFLOXACIN
69097028907 LEVOFLOXACIN
58657061010 LOSARTAN POTASSIUM
59762374101 MEDROXYPROGESTERONE ACETA
68382005105 MELOXICAM
23155010405 METFORMIN HCL
67877021710 METFORMIN HCL
00093529501 METHYLPHENIDATE HCL CD
62175015637 METHYLPHENIDATE HCL CD
00378190201 MIDODRINE HCL
16714070701 MIRTAZAPINE
57237000930 MIRTAZAPINE
00378557393 MODAFINIL
00713063515 MOMETASONE FUROATE
00713063537 MOMETASONE FUROATE
45802011846 MOMETASONE FUROATE
45802025742 MOMETASONE FUROATE
57237021390 MONTELUKAST SODIUM
60505296507 MYCOPHENOLIC ACID DR
00591367101 NABUMETONE
68462035801 NABUMETONE
59762081001 NADOLOL
00093100601 NAPROXEN DR
00574416035 NEOMYCIN/POLYMYXIN/DEXAME
00536137223 NICOTINE POLACRILEX
00378049401 NIFEDIPINE ER
47781030701 NITROFURANTOIN MACROCRYST
00168000730 NYSTATIN
00168005415 NYSTATIN
00168005430 NYSTATIN
51672411709 NYSTATIN
65862039110 ONDANSETRON ODT
10702000801 OXYCODONE HCL
64950035450 OXYCODONE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
77 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
65162004910 OXYCODONE HCL
68462020401 OXYCODONE HCL
42858010301 OXYCODONE/ACETAMINOPHEN
68308084101 OXYCODONE/ACETAMINOPHEN
43547034703 PAROXETINE HCL
00093412773 PENICILLIN V POTASSIUM
16714023401 PENICILLIN V POTASSIUM
65862017605 PENICILLIN V POTASSIUM
62756040203 PHENYTOIN SODIUM EXTENDED
00006483703 PNEUMOVAX 23
68382007205 PRAVASTATIN SODIUM
60432021208 PREDNISOLONE SODIUM PHOSP
59310057922 PROAIR HFA
00037682210 PROCTOFOAM HC
00603158658 PROMETHAZINE-DM
67877024901 QUETIAPINE FUMARATE
59572041028 REVLIMID
00378350291 RISPERIDONE
27241000150 RISPERIDONE
27241000250 RISPERIDONE
27241000350 RISPERIDONE
43547034050 RISPERIDONE
68462046706 RIZATRIPTAN BENZOATE ODT
00054011725 ROPINIROLE HCL
00054011925 ROPINIROLE HCL
16714061206 SERTRALINE HCL
49348049807 SM ASPIRIN ADULT LOW STRE
00487900360 SODIUM CHLORIDE
24208067004 SODIUM SULFACETAMIDE
42582060020 SODIUM SULFACETAMIDE/SULF
43598021055 SSD
61958120101 STRIBILD
59762040101 SUCRALFATE
53746027105 SULFAMETHOXAZOLE/TRIMETHO
59762500002 SULFASALAZINE
53489047901 SULINDAC
00781652486 SUMATRIPTAN
45802039000 TACROLIMUS
00078051005 TEGRETOL-XR
69097085907 TERBINAFINE HCL
60758080105 TIMOLOL MALEATE
64980051401 TIMOLOL MALEATE
69097012215 TOPIRAMATE
31722053001 TORSEMIDE
16714048102 TRAMADOL HCL
57664037713 TRAMADOL HCL
66530025320 TRETINOIN
66530025645 TRETINOIN
00603786274 TRIAMCINOLONE ACETONIDE
00781271501 TRIAMTERENE/HYDROCHLOROTH
59762371804 TRIAZOLAM
59762371809 TRIAZOLAM
00591557101 TRIMETHOPRIM
45963055930 VALACYCLOVIR HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
78 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
69097015302 VALACYCLOVIR HCL
69097015402 VALACYCLOVIR HCL
62332008090 VALSARTAN/HYDROCHLOROTHIA
62559039020 VANCOMYCIN HCL
51991060401 VITAMIN D
13811051690 VOL-TAB RX
63481068447 VOLTAREN
16714051501 VORICONAZOLE
00054008425 ZALEPLON
24208053535 ZIRGAN
00955170210 ZOLPIDEM TARTRATE ER
64896068151 ZOMIG
62756025902 ZONISAMIDE
00378633380 ACAMPROSATE CALCIUM DR
00527105001 ACETAZOLAMIDE
00093894301 ACYCLOVIR
31722077701 ACYCLOVIR
61442011301 ACYCLOVIR
66993088448 ADAPALENE
00173071520 ADVAIR HFA
65862032904 ALENDRONATE SODIUM
67253090210 ALPRAZOLAM
00781204801 AMANTADINE HCL
00603221521 AMITRIPTYLINE HCL
69097083605 AMLODIPINE BESYLATE
00093310705 AMOXICILLIN
00185083101 AMPHETAMINE/DEXTROAMPHETA
00378454701 AMPHETAMINE/DEXTROAMPHETA
00555077702 AMPHETAMINE/DEXTROAMPHETA
00093758356 ARIPIPRAZOLE
13811068030 ARIPIPRAZOLE
60505267403 ARIPIPRAZOLE
00904539261 ATENOLOL
64980037903 ATOMOXETINE
66993004330 ATOMOXETINE
66993004530 ATOMOXETINE
62175089741 ATORVASTATIN CALCIUM
68645048070 ATORVASTATIN CALCIUM
66993089749 AUGMENTED BETAMETHASONE D
00002197590 AXIRON
68180016106 AZITHROMYCIN
16714007106 BACLOFEN
00173038879 BECONASE AQ
51672127401 BETAMETHASONE DIPROPIONAT
00168004160 BETAMETHASONE VALERATE
23155019101 BUPROPION HCL
43547028950 BUPROPION HCL ER
00591333130 BUPROPION HCL XL
68180032002 BUPROPION HCL XL
69097087502 BUPROPION HCL XL
65862021901 CEFDINIR
68180072210 CEFDINIR
00591398301 CELECOXIB
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
79 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
60505384905 CELECOXIB
00093314501 CEPHALEXIN
45802013811 CICLOPIROX OLAMINE
51672131802 CICLOPIROX OLAMINE
16252051401 CIPROFLOXACIN HCL
59762001601 CLINDAMYCIN PALMITATE HCL
52565001859 CLINDAMYCIN PHOSPHATE
59762500901 CLINDAMYCIN PHOSPHATE
00378868854 CLINDAMYCIN/BENZOYL PEROX
00574206302 CLOBETASOL PROPIONATE
50383026650 CLOBETASOL PROPIONATE
50383026730 CLOBETASOL PROPIONATE
00168030130 CLOBETASOL PROPIONATE EMO
00185006310 CLONAZEPAM
00591351004 CLONIDINE HCL
65862035730 CLOPIDOGREL
00378004001 CLORAZEPATE DIPOTASSIUM
00472037945 CLOTRIMAZOLE/BETAMETHASON
00093435901 CLOZAPINE
00093440505 CLOZAPINE
59762045001 COLESTIPOL HCL
00023921110 COMBIGAN
00378075101 CYCLOBENZAPRINE HCL
51672128001 DESONIDE
45802049537 DESOXIMETASONE
00054418025 DEXAMETHASONE
10702006601 DEXTROAMPHETAMINE SULFATE
00378047701 DIAZEPAM
61442010201 DICLOFENAC SODIUM DR
47781060730 DISULFIRAM
62756079788 DIVALPROEX SODIUM DR
13668010310 DONEPEZIL HCL
59762234006 DOXAZOSIN MESYLATE
69238117009 DOXEPIN HCL
52652400101 EPANED
54505010102 EPINEPHRINE
54458089110 ESCITALOPRAM OXALATE
00378464126 ESTRADIOL
00093553756 ESZOPICLONE
00378304001 FAMOTIDINE
58160090552 FLUARIX QUADRIVALENT 2016
52343008722 FLUCONAZOLE
55111014601 FLUCONAZOLE
19515090311 FLULAVAL QUADRIVALENT 201
00093026215 FLUOCINONIDE
51672411806 FLUOROURACIL
31722090305 FLUOXETINE HCL
31722090410 FLUOXETINE HCL
49281039965 FLUZONE HIGH-DOSE PF 2016
00603316221 FOLIC ACID
00378023201 FUROSEMIDE
45963055511 GABAPENTIN
52343003190 GABAPENTIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
80 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
60505011301 GABAPENTIN
45802004611 GENTAMICIN SULFATE
90166013004 GLOBAL INJECT EASE LANCET
00169706515 GLUCAGEN HYPOKIT
00093936401 GLYBURIDE
00378106201 GUANFACINE ER
50111032803 HYDRALAZINE HCL
00591034701 HYDROCHLOROTHIAZIDE
00121077216 HYDROCODONE BITARTRATE/AC
00472033720 HYDROCORTISONE
45802093716 HYDROCORTISONE
51672129206 HYDROCORTISONE VALERATE
63304029605 HYDROXYCHLOROQUINE SULFAT
00185061505 HYDROXYZINE PAMOATE
53746046501 IBUPROFEN
53746046601 IBUPROFEN
68462030205 INDOMETHACIN
00143177101 ISOSORBIDE DINITRATE
00832121300 JANTOVEN
17478020919 KETOROLAC TROMETHAMINE
16714037102 LAMOTRIGINE
68382000810 LAMOTRIGINE
69097015203 LAMOTRIGINE
23155004303 LEFLUNOMIDE
16714035401 LEVETIRACETAM
65862024608 LEVETIRACETAM
24208050505 LEVOBUNOLOL HCL
68382001518 LEVOFLOXACIN
00378181301 LEVOTHYROXINE SODIUM
00115146845 LIDOCAINE/PRILOCAINE
54458099809 LISINOPRIL
31722070090 LOSARTAN POTASSIUM
31722070290 LOSARTAN POTASSIUM
65862020330 LOSARTAN POTASSIUM
62332004891 LOSARTAN POTASSIUM/HYDROC
24208029910 LOTEMAX
61442012601 MELOXICAM
45802009851 MESALAMINE
43547035711 METFORMIN HCL
57664039758 METFORMIN HCL
67877056110 METFORMIN HYDROCHLORIDE
00406577101 METHADONE HCL
64980026101 METHIMAZOLE
00093529601 METHYLPHENIDATE HCL CD
62175015137 METHYLPHENIDATE HCL CD
00378815677 METHYLPHENIDATE HCL ER
62175031037 METHYLPHENIDATE HCL ER
59746000314 METHYLPREDNISOLONE
00115165201 METOCLOPRAMIDE HCL
49884068905 METOCLOPRAMIDE HCL
57237010201 METOPROLOL TARTRATE
00591564201 MINOXIDIL
57237000730 MIRTAZAPINE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
81 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
57237000830 MIRTAZAPINE
60505024708 MIRTAZAPINE
62332010690 MODAFINIL
00781635587 MOMETASONE FUROATE
65162089129 MOMETASONE FUROATE
27241001531 MONTELUKAST SODIUM
61748030213 MYORISAN
61748030313 MYORISAN
65162019010 NAPROXEN
00378036001 NIFEDIPINE ER
62175026137 NIFEDIPINE ER
62175026155 NIFEDIPINE ER
00115164301 NITROFURANTOIN MACROCRYST
43598043601 NITROGLYCERIN
00071041813 NITROSTAT
00591578801 NORTRIPTYLINE HCL
00169185275 NOVOFINE AUTOCOVER 30GX8M
00832046515 NYAMYC
00603148158 NYSTATIN
60505036301 OFLOXACIN
60505311108 OLANZAPINE
00378615001 OMEPRAZOLE
68462039530 OMEPRAZOLE
68462039630 OMEPRAZOLE
64980021001 OXYBUTYNIN CHLORIDE ER
00781572601 OXYCODONE HCL ER
00603499821 OXYCODONE/ACETAMINOPHEN
42858010401 OXYCODONE/ACETAMINOPHEN
43547034709 PAROXETINE HCL
42192080201 PHENAZOPYRIDINE HCL
00574018101 POTASSIUM CHLORIDE ER
00781572001 POTASSIUM CHLORIDE ER
57599074501 PRECISION XTRA
00603533928 PREDNISONE
00093965201 PROCHLORPERAZINE MALEATE
00469060773 PROGRAF
23155011101 PROPRANOLOL HCL
23155011201 PROPRANOLOL HCL
50111046703 PROPRANOLOL HCL
50111046801 PROPRANOLOL HCL
00054022925 QUETIAPINE FUMARATE
16729014717 QUETIAPINE FUMARATE
00310828460 QUETIAPINE FUMARATE ER
49884080802 QUETIAPINE FUMARATE ER
59148003713 REXULTI
68382011514 RISPERIDONE
68462046699 RIZATRIPTAN BENZOATE
68645050001 SERTRALINE HCL
00093715598 SIMVASTATIN
16729000715 SIMVASTATIN
44946103208 SODIUM FLUORIDE
00603576328 SPIRONOLACTONE
43598021040 SSD
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
82 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00002322730 STRATTERA
42192013612 SULFACETAMIDE SODIUM/SULF
00527185943 SUMATRIPTAN
16714053211 SUMATRIPTAN SUCCINATE
62756052069 SUMATRIPTAN SUCCINATE
00168041730 TACROLIMUS
00378226401 TERAZOSIN HCL
00591321730 TESTOSTERONE
62756001540 TESTOSTERONE CYPIONATE
42858070101 THEOPHYLLINE ER
55111018010 TIZANIDINE HCL
65162091446 TOBRAMYCIN
31722053201 TORSEMIDE
00378415105 TRAMADOL HCL
10019055303 TRANSDERM-SCOP
66530026045 TRETINOIN MICROSPHERE
45802005435 TRIAMCINOLONE ACETONIDE
61314004475 TRIFLURIDINE
00574014560 TROSPIUM CHLORIDE
69097091203 TROSPIUM CHLORIDE
00574011830 TROSPIUM CHLORIDE ER
31722074790 VALSARTAN
51660014190 VALSARTAN
00409653301 VANCOMYCIN HCL
65162030609 VENLAFAXINE HCL
66582031531 VYTORIN
65162076610 WARFARIN SODIUM
55111013781 ZENATANE
68180033207 ZIPRASIDONE HCL
13668000701 ZOLPIDEM TARTRATE
00006496301 ZOSTAVAX
24208035805 ZYLET
13107005999 ACETAMINOPHEN/CODEINE
60505530701 ACYCLOVIR
61442011101 ACYCLOVIR
00023520660 ACZONE
00023520690 ACZONE
33332031701 AFLURIA QUADRIVALENT 2017
33332041710 AFLURIA QUADRIVALENT 2017
00591379783 ALBUTEROL SULFATE
00591554310 ALLOPURINOL
00603211521 ALLOPURINOL
00603211532 ALLOPURINOL
53489015705 ALLOPURINOL
53489015710 ALLOPURINOL
49884011701 AMILORIDE HCL
51862015430 AMIODARONE HCL
51862015630 AMIODARONE HCL
16714044702 AMITRIPTYLINE HCL
16714044801 AMITRIPTYLINE HCL
00054010228 AMLODIPINE BESYLATE
29300024205 AMLODIPINE BESYLATE
42806005710 AMLODIPINE BESYLATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
83 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
68382012116 AMLODIPINE BESYLATE
00591376001 AMLODIPINE BESYLATE/BENAZ
55111034001 AMLODIPINE BESYLATE/BENAZ
57237014601 AMLODIPINE BESYLATE/BENAZ
65862058701 AMLODIPINE BESYLATE/BENAZ
00781261301 AMOXICILLIN
00378454301 AMPHETAMINE/DEXTROAMPHETA
31722082930 ARIPIPRAZOLE
60505267603 ARIPIPRAZOLE
00093309456 ARMODAFINIL
00591385630 ARMODAFINIL
00781803731 ARMODAFINIL
00536100410 ASPIRIN
00904770470 ASPIR-LOW
00781522501 ATENOLOL
68382002301 ATENOLOL
64980037303 ATOMOXETINE
66993004430 ATOMOXETINE
00093505698 ATORVASTATIN CALCIUM
00093505798 ATORVASTATIN CALCIUM
00378395309 ATORVASTATIN CALCIUM
55111012205 ATORVASTATIN CALCIUM
55111012405 ATORVASTATIN CALCIUM
59762015802 ATORVASTATIN CALCIUM
62175089241 ATORVASTATIN CALCIUM
62175089246 ATORVASTATIN CALCIUM
68645045854 ATORVASTATIN CALCIUM
68645045870 ATORVASTATIN CALCIUM
69097089812 ATORVASTATIN CALCIUM
45802037632 AUGMENTED BETAMETHASONE D
51672131003 AUGMENTED BETAMETHASONE D
00574402235 BACITRACIN
00555903458 BALZIVA
43547033810 BENAZEPRIL HCL
65162075210 BENAZEPRIL HCL
51224000160 BENZONATATE
64380071207 BENZONATATE
00603243821 BENZTROPINE MESYLATE
76385010401 BENZTROPINE MESYLATE
17478071510 BRIMONIDINE TARTRATE
24208041110 BRIMONIDINE TARTRATE
61314014310 BRIMONIDINE TARTRATE
42799011901 BUMETANIDE
43547028809 BUPROPION HCL ER
00591354260 BUPROPION HCL SR
68382035405 BUPROPION HCL XL
00310651201 BYETTA
49884067314 CABERGOLINE
23155053102 CALCIUM ACETATE
00093614882 CAMRESE LO
49884066109 CANDESARTAN CILEXETIL
60505280607 CARBAMAZEPINE ER
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
84 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
65862014405 CARVEDILOL
68462016205 CARVEDILOL
68180018001 CEFADROXIL
16714039102 CEFDINIR
42043025238 CEFDINIR
68180040203 CEFPROZIL
65862069960 CEFUROXIME AXETIL
33342015715 CELECOXIB
69543010250 CEPHALEXIN
51672530200 CICLOPIROX NAIL LACQUER
68462029735 CICLOPIROX OLAMINE
00143992801 CIPROFLOXACIN HCL
00713474201 CITALOPRAM HYDROBROMIDE
59746054405 CITALOPRAM HYDROBROMIDE
59746054601 CITALOPRAM HYDROBROMIDE
65162005310 CITALOPRAM HYDROBROMIDE
65862000701 CITALOPRAM HYDROBROMIDE
76282020710 CITALOPRAM HYDROBROMIDE
00527138301 CLINDAMYCIN HCL
63304069201 CLINDAMYCIN HCL
00168020160 CLINDAMYCIN PHOSPHATE
00168016215 CLOBETASOL PROPIONATE
00168016230 CLOBETASOL PROPIONATE
00168016246 CLOBETASOL PROPIONATE
00781713704 CLOBETASOL PROPIONATE
40085088850 CLOBETASOL PROPIONATE
45802043732 CLOBETASOL PROPIONATE
51672125806 CLOBETASOL PROPIONATE
51672125901 CLOBETASOL PROPIONATE
00378302501 CLOMIPRAMINE HCL
00185006301 CLONAZEPAM
00781556710 CLONAZEPAM
33342006015 CLOPIDOGREL
55111019630 CLOPIDOGREL
66993089815 CLOTRIMAZOLE/BETAMETHASON
17478029111 CROMOLYN SODIUM
00143962101 CYANOCOBALAMIN
00603752117 CYCLAFEM 1/35
16714044004 DEBLITANE
00472080460 DESONIDE
51672128003 DESONIDE
51672128103 DESONIDE
00472047860 DESOXIMETASONE
51672127001 DESOXIMETASONE
51672127103 DESOXIMETASONE
00591406030 DESVENLAFAXINE ER
51991031290 DESVENLAFAXINE ER
00009519102 DETROL LA
00054317757 DEXAMETHASONE
00093555101 DEXMETHYLPHENIDATE HCL ER
00781268601 DEXMETHYLPHENIDATE HCL ER
00406896201 DEXTROAMPHETAMINE SULFATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
85 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00228255011 DICLOFENAC SODIUM DR
00591039860 DICLOFENAC SODIUM/MISOPRO
00591079410 DICYCLOMINE HCL
49884083111 DILTIAZEM CD
00378004501 DILTIAZEM HCL
68682036790 DILTIAZEM HCL ER
00832712411 DIVALPROEX SODIUM DR
29300014005 DIVALPROEX SODIUM DR
62756079888 DIVALPROEX SODIUM DR
31722073890 DONEPEZIL HCL
00378402401 DOXAZOSIN
67253038010 DOXAZOSIN MESYLATE
68645046354 DOXAZOSIN MESYLATE
68645046370 DOXAZOSIN MESYLATE
69238116609 DOXEPIN HCL
27241009903 DULOXETINE HCL
31722058330 DULOXETINE HCL
47335038283 DULOXETINE HCL
68180029603 DULOXETINE HCL
00591377130 DUTASTERIDE/TAMSULOSIN HC
00603754017 EMOQUETTE
00093002701 ENALAPRIL MALEATE
16714044501 ENALAPRIL MALEATE
64679092402 ENALAPRIL MALEATE
64679092602 ENALAPRIL MALEATE
68645045590 ENALAPRIL MALEATE
00548560500 ENOXAPARIN SODIUM
00781350069 ENOXAPARIN SODIUM
68180088211 ENSKYCE
60505058401 EPINASTINE HCL
24338012413 ERY-TAB
00168021630 ERYTHROMYCIN
00574402450 ERYTHROMYCIN
17478007031 ERYTHROMYCIN
45802096696 ERYTHROMYCIN
24338010413 ERYTHROMYCIN BASE
00378385710 ESCITALOPRAM OXALATE
65862078430 ESOMEPRAZOLE MAGNESIUM
00591048801 ESTRADIOL
45963056630 EZETIMIBE/SIMVASTATIN
61442012210 FAMOTIDINE
68180036009 FENOFIBRATE
00378912498 FENTANYL
31722052510 FINASTERIDE
65862014990 FINASTERIDE
67877028890 FINASTERIDE
68645044670 FINASTERIDE
65162064110 FLECAINIDE ACETATE
65862062101 FLECAINIDE ACETATE
60793041130 FLECTOR
16714069102 FLUCONAZOLE
16714069301 FLUCONAZOLE
57237014935 FLUCONAZOLE
67405060203 FLUCONAZOLE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
86 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00093026292 FLUOCINONIDE
16714050202 FLUOCINONIDE
51672125303 FLUOCINONIDE
51672126401 FLUOCINONIDE
51672138602 FLUOCINONIDE
31722090501 FLUOXETINE HCL
42543072501 FLUOXETINE HCL
50111064802 FLUOXETINE HCL
00093071101 FLURBIPROFEN
11534016503 FOLIC ACID
65162036110 FOLIC ACID
69315012701 FOLIC ACID
00378314085 FROVATRIPTAN SUCCINATE
64125011710 FUROSEMIDE
00904563261 GABAPENTIN
16714050401 GABAPENTIN
49483060550 GABAPENTIN
69097081407 GABAPENTIN
43386005019 GAVILYTE-N/FLAVOR PACK
16714010102 GEMFIBROZIL
42806026005 GEMFIBROZIL
69097082103 GEMFIBROZIL
17478028435 GENTAK
60505014201 GLIPIZIDE
10370019005 GLIPIZIDE ER
65862008101 GLYBURIDE/METFORMIN HCL
00093596301 GUANFACINE ER
61958180101 HARVONI
00172208360 HYDROCHLOROTHIAZIDE
00603385721 HYDROCHLOROTHIAZIDE
57237000299 HYDROCHLOROTHIAZIDE
00713070489 HYDROCODONE BITARTRATE/AC
00406012405 HYDROCODONE/ACETAMINOPHEN
00603360921 HYDROCODONE/ACETAMINOPHEN
00603389032 HYDROCODONE/ACETAMINOPHEN
43386035601 HYDROCODONE/ACETAMINOPHEN
54838050280 HYDROXYZINE HCL
00591080005 HYDROXYZINE PAMOATE
42192033901 HYOSCYAMINE SULFATE
00591377031 IBANDRONATE SODIUM
55111068201 IBUPROFEN
55111068205 IBUPROFEN
68462053670 IMIQUIMOD
00054025013 IRBESARTAN
43547027709 IRBESARTAN
43547037503 IRBESARTAN
43547037650 IRBESARTAN
59746044990 IRBESARTAN
33342005707 IRBESARTAN/HYDROCHLOROTHI
65162063003 ITRACONAZOLE
00832121500 JANTOVEN
00093312298 JINTELI
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
87 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378026101 KETOCONAZOLE
51672129801 KETOCONAZOLE
00093319501 KETOPROFEN
66658023407 KINERET
00185011705 LABETALOL HCL
51672413101 LAMOTRIGINE
59746024601 LAMOTRIGINE
45963046110 LANSOPRAZOLE
68382054401 LANSOPRAZOLE
60505325503 LETROZOLE
16714035801 LEVETIRACETAM
43547022406 LEVETIRACETAM
64980050312 LEVOCARNITINE
00093770198 LEVOCETIRIZINE DIHYDROCHL
69097028970 LEVOFLOXACIN
00378728490 LEVONORGESTREL AND ETHINY
68180084813 LEVONORGESTREL AND ETHINY
00378728753 LEVONORGESTREL/ETHINYL ES
00527134910 LEVOTHYROXINE SODIUM
00781518610 LEVOTHYROXINE SODIUM
00378361201 LIOTHYRONINE SODIUM
00574022201 LIOTHYRONINE SODIUM
00185060201 LISINOPRIL
00378207301 LISINOPRIL
00591040905 LISINOPRIL
00603421428 LISINOPRIL
16729019401 LISINOPRIL
16729037717 LISINOPRIL
68001026708 LISINOPRIL
68001033508 LISINOPRIL
68001033708 LISINOPRIL
76282042045 LISINOPRIL
76282042210 LISINOPRIL
00185017301 LISINOPRIL/HYDROCHLOROTHI
31722070210 LOSARTAN POTASSIUM
33342004544 LOSARTAN POTASSIUM
42571011010 LOSARTAN POTASSIUM
59746033310 LOSARTAN POTASSIUM
59746033510 LOSARTAN POTASSIUM
65862020230 LOSARTAN POTASSIUM
68180021203 LOSARTAN POTASSIUM
13668011830 LOSARTAN POTASSIUM/HYDROC
24208044335 LOTEMAX
54458084416 LOVASTATIN
00054002511 MEFLOQUINE HCL
33342029809 MEMANTINE HCL
47335032186 MEMANTINE HCL
47335032286 MEMANTINE HCL
53746016930 MEMANTINE HCL
23155010201 METFORMIN HCL
23155010310 METFORMIN HCL
60429011318 METFORMIN HCL
67877022110 METFORMIN HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
88 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378600191 METFORMIN HCL ER
67877015901 METFORMIN HCL ER
27437005057 METHERGINE
23155007101 METHIMAZOLE
49884064001 METHIMAZOLE
00143129201 METHOCARBAMOL
00603448628 METHOCARBAMOL
00703367501 METHOTREXATE SODIUM
00378042101 METHYLDOPA
00781574801 METHYLPHENIDATE HCL
00781575301 METHYLPHENIDATE HCL
57664022888 METHYLPHENIDATE HCL
00378815577 METHYLPHENIDATE HCL ER
13811070710 METHYLPHENIDATE HCL ER
62175031137 METHYLPHENIDATE HCL ER
62175031237 METHYLPHENIDATE HCL ER
59746001504 METHYLPREDNISOLONE
59762005101 METHYLPREDNISOLONE
00185505001 METOLAZONE
65580064371 METOLAZONE
57237010101 METOPROLOL TARTRATE
57664016752 METOPROLOL TARTRATE
62332011291 METOPROLOL TARTRATE
00378042401 METOPROLOL/HYDROCHLOROTHI
62332011531 METOPROLOL/HYDROCHLOROTHI
52544027621 MICROGESTIN 1/20
00185004301 MIDODRINE HCL
00093720856 MIRTAZAPINE
60505024801 MIRTAZAPINE
50742015390 MODAFINIL
62332010530 MODAFINIL
62332038630 MODAFINIL
45802025735 MOMETASONE FUROATE
00054025913 MONTELUKAST SODIUM
00054028913 MONTELUKAST SODIUM
00603465532 MONTELUKAST SODIUM
16729011910 MONTELUKAST SODIUM
29300022013 MONTELUKAST SODIUM
00054023525 MORPHINE SULFATE
00054023749 MORPHINE SULFATE
42858080201 MORPHINE SULFATE ER
68382090301 MORPHINE SULFATE ER
00054016629 MYCOPHENOLATE MOFETIL
00093101501 NABUMETONE
00093101601 NABUMETONE
31722034101 NAPROXEN
49483061850 NAPROXEN
69097085307 NAPROXEN
51862031803 NECON 0.5/35-28
00093517301 NIFEDICAL XL
00093517355 NIFEDICAL XL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
89 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
10370067701 NIFEDIPINE ER
00378165001 NITROFURANTOIN MACROCRYST
00378727753 NORGESTIMATE/ETHINYL ESTR
00555900867 NORTREL 0.5/35 (28)
00169185550 NOVOFINE PLUS 32GX4MM
00121081016 NYSTATIN
00168000715 NYSTATIN
00713067831 NYSTATIN
42543005263 NYSTATIN
45802004835 NYSTATIN
51672411704 NYSTATIN
50383002505 OFLOXACIN
50383002510 OFLOXACIN
33342006807 OLANZAPINE
66993068030 OLANZAPINE
17478010505 OLOPATADINE HCL
00378521195 OMEPRAZOLE
55111015930 OMEPRAZOLE
62175013632 OMEPRAZOLE
00054006447 ONDANSETRON HCL
57237007530 ONDANSETRON HCL
63304045930 ONDANSETRON HCL
53885024450 ONETOUCH ULTRA BLUE
50458019115 ORTHO TRI-CYCLEN
00054009925 OXCARBAZEPINE
62756018488 OXCARBAZEPINE
16729031701 OXYBUTYNIN CHLORIDE ER
00603499021 OXYCODONE HCL
00093573301 OXYCODONE HCL ER
63304068301 OXYCODONE HCL ER
00378668977 PANTOPRAZOLE SODIUM
62175061743 PANTOPRAZOLE SODIUM
13107015630 PAROXETINE HCL
54458098816 PAROXETINE HCL
54458098916 PAROXETINE HCL
54458099016 PAROXETINE HCL
60505008302 PAROXETINE HCL
60505009702 PAROXETINE HCL
00781165501 PENICILLIN V POTASSIUM
16714023502 PENICILLIN V POTASSIUM
00093727198 PIOGLITAZONE HCL
68180089313 PIRMELLA 1/35
00093075701 PIROXICAM
00574018190 POTASSIUM CHLORIDE ER
00574027401 POTASSIUM CHLORIDE ER
62037055901 POTASSIUM CHLORIDE ER
68382019916 PRAMIPEXOLE DIHYDROCHLORI
00378518693 PRASUGREL
60505464303 PRASUGREL
16252052790 PRAVASTATIN SODIUM
16252052890 PRAVASTATIN SODIUM
16729001115 PRAVASTATIN SODIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
90 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
54458092616 PRAVASTATIN SODIUM
68382007116 PRAVASTATIN SODIUM
11980017405 PRED MILD
50383004004 PREDNISOLONE SODIUM PHOSP
00603533821 PREDNISONE
00603533828 PREDNISONE
69387010101 PROGESTERONE
69387010201 PROGESTERONE
65162074510 PROMETHAZINE HCL
00115166103 PROPRANOLOL HCL
00378018201 PROPRANOLOL HCL
00591555601 PROPRANOLOL HCL
00603548621 PROPRANOLOL HCL
50111046803 PROPRANOLOL HCL
50111047101 PROPRANOLOL HCL
16714045201 QUETIAPINE FUMARATE
16729014517 QUETIAPINE FUMARATE
67877024801 QUETIAPINE FUMARATE
68180055809 QUINAPRIL HCL
13668010790 RABEPRAZOLE SODIUM
65162072403 RABEPRAZOLE SODIUM
00591236701 RALOXIFENE HYDROCHLORIDE
69097082502 RALOXIFENE HYDROCHLORIDE
00054010925 RAMIPRIL
68382014501 RAMIPRIL
61958100401 RANEXA
53746025430 RANITIDINE HCL
00049234005 RELPAX
47335092860 RISEDRONATE SODIUM
50458059160 RISPERIDONE
00591320860 RIVASTIGMINE TARTRATE
57237008863 RIZATRIPTAN BENZOATE
00378370259 RIZATRIPTAN BENZOATE ODT
62332003031 ROPINIROLE HCL
00093757298 ROSUVASTATIN CALCIUM
00378220177 ROSUVASTATIN CALCIUM
00781540092 ROSUVASTATIN CALCIUM
00781540331 ROSUVASTATIN CALCIUM
13668018130 ROSUVASTATIN CALCIUM
16252061730 ROSUVASTATIN CALCIUM
16729028710 ROSUVASTATIN CALCIUM
57237016990 ROSUVASTATIN CALCIUM
57237016999 ROSUVASTATIN CALCIUM
68462026430 ROSUVASTATIN CALCIUM
50484001090 SANTYL
00456151260 SAVELLA
45802004064 SELENIUM SULFIDE
60432052804 SELENIUM SULFIDE
68645052154 SERTRALINE HCL
55111078927 SEVELAMER CARBONATE
00093715398 SIMVASTATIN
16714068402 SIMVASTATIN
31722051490 SIMVASTATIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
91 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
54458093416 SIMVASTATIN
68382006705 SIMVASTATIN
68382006716 SIMVASTATIN
68382006816 SIMVASTATIN
00299382330 SOOLANTRA
00603576921 SOTALOL HCL
00597007547 SPIRIVA HANDIHALER
16729022501 SPIRONOLACTONE
53489032801 SPIRONOLACTONE
53746051505 SPIRONOLACTONE
00378040301 SPIRONOLACTONE/HYDROCHLOR
00003085222 SPRYCEL
52544096728 SRONYX
00002325130 STRATTERA
00597019261 STRIVERDI RESPIMAT
42192013606 SULFACETAMIDE SODIUM/SULF
00781652386 SUMATRIPTAN
00378563059 SUMATRIPTAN SUCCINATE
00781317207 SUMATRIPTAN SUCCINATE
00597016818 SYNJARDY
00074518211 SYNTHROID
00168041660 TACROLIMUS
00168041699 TACROLIMUS
51862045090 TAMOXIFEN CITRATE
00023004203 TAZORAC
00023915630 TAZORAC
68462020113 TELMISARTAN
00406996001 TEMAZEPAM
00781205401 TERAZOSIN HCL
62756001640 TESTOSTERONE CYPIONATE
61314022505 TIMOLOL MALEATE OPHTHALMI
29300016910 TIZANIDINE HCL
00065064835 TOBRADEX
00065064435 TOBREX
59762004701 TOLTERODINE TARTRATE ER
31722027960 TOPIRAMATE
68382000414 TOPIRAMATE
68462010960 TOPIRAMATE
68462011060 TOPIRAMATE
65162062710 TRAMADOL HCL
00472011720 TRETINOIN
00168000416 TRIAMCINOLONE ACETONIDE
00603786278 TRIAMCINOLONE ACETONIDE
00603786449 TRIAMCINOLONE ACETONIDE
00713022815 TRIAMCINOLONE ACETONIDE
00713022880 TRIAMCINOLONE ACETONIDE
00378135505 TRIAMTERENE/HYDROCHLOROTH
00378253701 TRIAMTERENE/HYDROCHLOROTH
68001021600 TRIAMTERENE/HYDROCHLOROTH
60505345406 TROSPIUM CHLORIDE
58160081511 TWINRIX
54295030824 UREA
00591300501 URSODIOL
00169517604 VAGIFEM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
92 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00093725998 VALACYCLOVIR HCL
45963055830 VALACYCLOVIR HCL
63304090530 VALACYCLOVIR HCL
69097015405 VALACYCLOVIR HCL
00378581577 VALSARTAN
00591231619 VALSARTAN/HYDROCHLOROTHIA
17478074102 VANCOMYCIN HCL
47781072950 VANCOMYCIN HCL
16714065601 VENLAFAXINE HCL
57237017301 VENLAFAXINE HCL
57664039588 VENLAFAXINE HCL
65162030709 VENLAFAXINE HCL
68382002101 VENLAFAXINE HCL
13811071530 VENLAFAXINE HCL ER
59762018001 VENLAFAXINE HCL ER
00069422066 VIAGRA
00078034442 VIVELLE-DOT
66582031254 VYTORIN
65162076710 WARFARIN SODIUM
50419040503 YAZ
66582041454 ZETIA
66993048532 ZILEUTON ER
00378530501 ZOLPIDEM TARTRATE
68001024300 ZONISAMIDE
68462012901 ZONISAMIDE
00006496300 ZOSTAVAX
23155028701 ACETAZOLAMIDE
23155012001 ACETAZOLAMIDE ER
60432074115 ACETIC ACID
00378870006 ACYCLOVIR
00472008216 ACYCLOVIR
51672137706 ADAPALENE
00378827093 ALBUTEROL SULFATE
00487030101 ALBUTEROL SULFATE
67546011112 ALINIA
67253090011 ALPRAZOLAM
00024542131 AMBIEN
00603221221 AMITRIPTYLINE HCL
00378661293 AMNESTEEM
00093416176 AMOXICILLIN
00143988980 AMOXICILLIN
00781615757 AMOXICILLIN
16714029903 AMOXICILLIN
00093227434 AMOXICILLIN/CLAVULANATE P
00093867575 AMOXICILLIN/CLAVULANATE P
00378083201 AMOXICILLIN/CLAVULANATE P
00781613948 AMOXICILLIN/CLAVULANATE P
16714029302 AMOXICILLIN/CLAVULANATE P
16714049401 AMOXICILLIN/CLAVULANATE P
43598020452 AMOXICILLIN/CLAVULANATE P
00185085301 AMPHETAMINE/DEXTROAMPHETA
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
93 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00378454601 AMPHETAMINE/DEXTROAMPHETA
67253018110 AMPICILLIN
00051846230 ANDROGEL
13668021690 ARIPIPRAZOLE
65162089803 ARIPIPRAZOLE
66993004030 ATOMOXETINE
66993004230 ATOMOXETINE
00378416001 ATOVAQUONE/PROGUANIL HCL
68462040201 ATOVAQUONE/PROGUANIL HCL
00168026760 AUGMENTED BETAMETHASONE D
00472038215 AUGMENTED BETAMETHASONE D
17478030703 AZASITE
50111078855 AZITHROMYCIN
59762311001 AZITHROMYCIN
00527133010 BACLOFEN
00603240632 BACLOFEN
00603240728 BACLOFEN
00603240732 BACLOFEN
00832102400 BACLOFEN
67877057301 BENZONATATE
00603243721 BENZTROPINE MESYLATE
00472037045 BETAMETHASONE VALERATE
00713032715 BETAMETHASONE VALERATE
51672126906 BETAMETHASONE VALERATE
54879000460 BETAMETHASONE VALERATE
17478070510 BETAXOLOL HCL
00186077739 BRILINTA
00093423401 BUMETANIDE
00185041552 BUPROPION HCL SR
00591354160 BUPROPION HCL SR
00093100305 BUSPIRONE HCL
00378114001 BUSPIRONE HCL
16729020001 BUSPIRONE HCL
66993087878 CALCIPOTRIENE
60505280707 CARBAMAZEPINE ER
00378363205 CARVEDILOL
65862014301 CARVEDILOL
42043025006 CEFDINIR
65862017760 CEFDINIR
16714039901 CEFPROZIL
16714040102 CEFUROXIME AXETIL
57237005820 CEFUROXIME AXETIL
57237005920 CEFUROXIME AXETIL
67877021660 CEFUROXIME AXETIL
42043014001 CEPHALEXIN
42043014338 CEPHALEXIN
67877021905 CEPHALEXIN
00832030100 CHLORPROMAZINE HCL
45802013818 CICLOPIROX OLAMINE
16252051501 CIPROFLOXACIN HCL
61442022201 CIPROFLOXACIN HCL
61442022301 CIPROFLOXACIN HCL
65862007850 CIPROFLOXACIN HCL
59746054605 CITALOPRAM HYDROBROMIDE
00009766701 CLEOCIN
63304069205 CLINDAMYCIN HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
94 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00168020130 CLINDAMYCIN PHOSPHATE
00168027740 CLINDAMYCIN PHOSPHATE
51672408103 CLINDAMYCIN PHOSPHATE
59762372802 CLINDAMYCIN PHOSPHATE
00168016315 CLOBETASOL PROPIONATE
00168016330 CLOBETASOL PROPIONATE
00713065637 CLOBETASOL PROPIONATE
40085089350 CLOBETASOL PROPIONATE
50383026845 CLOBETASOL PROPIONATE
00093083401 CLONAZEPAM
00185006405 CLONAZEPAM
00228300450 CLONAZEPAM
51862045304 CLONIDINE HCL
68001023703 CLONIDINE HCL
00037683015 CORTIFOAM
00078063941 COSENTYX SENSOREADY PEN
00310075590 CRESTOR
50428173013 CVS NICOTINE TRANSDERMAL
00591565801 CYCLOBENZAPRINE HCL
60429005230 CYCLOBENZAPRINE HCL
24208073501 CYCLOPENTOLATE HCL
00002327030 CYMBALTA
64980050448 CYPROHEPTADINE HCL
00115164701 DESMOPRESSIN ACETATE
45802042235 DESONIDE
51672127003 DESOXIMETASONE
64980050924 DEXAMETHASONE
63323016501 DEXAMETHASONE SODIUM PHOS
00781268501 DEXMETHYLPHENIDATE HCL ER
45963080611 DEXMETHYLPHENIDATE HCL ER
00378107201 DEXTROAMPHETAMINE SULFATE
51862034690 DEXTROAMPHETAMINE SULFATE
00172392570 DIAZEPAM
00054318544 DIAZEPAM INTENSOL
00228255106 DICLOFENAC SODIUM DR
00591067601 DICLOFENAC SODIUM ER
49884083009 DILTIAZEM CD
00378528005 DILTIAZEM HCL ER
10370082911 DILTIAZEM HCL ER
59762106102 DIPHENOXYLATE/ATROPINE
62559049001 DIPHENOXYLATE/ATROPINE
00093503501 DISULFIRAM
57237010601 DIVALPROEX SODIUM DR
10370051050 DIVALPROEX SODIUM ER
24208048510 DORZOLAMIDE HCL
68645046454 DOXAZOSIN
00591555350 DOXYCYCLINE HYCLATE
00228289103 DULOXETINE HCL
47335038318 DULOXETINE HCL
45802046635 ECONAZOLE NITRATE
58160082152 ENGERIX-B
00955100610 ENOXAPARIN SODIUM
62037086320 ENOXAPARIN SODIUM
62037086420 ENOXAPARIN SODIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
95 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
52652100101 EPANED
00574402439 ERYTHROMYCIN
54458089210 ESCITALOPRAM OXALATE
65862037305 ESCITALOPRAM OXALATE
65862037405 ESCITALOPRAM OXALATE
00781712983 ESTRADIOL
00054029125 ESZOPICLONE
00378527001 ESZOPICLONE
47335058788 ESZOPICLONE
47335058888 ESZOPICLONE
55111061901 ESZOPICLONE
00115138808 EZETIMIBE/SIMVASTATIN
00093811956 FAMCICLOVIR
33342002507 FAMCICLOVIR
33342002607 FAMCICLOVIR
60505700902 FENTANYL
42874011710 FLUBLOK QUADRIVALENT 2017
70461020001 FLUCELVAX QUADRIVALENT 20
00172541346 FLUCONAZOLE
16714069101 FLUCONAZOLE
68001025320 FLUCONAZOLE
51672135608 FLUOCINOLONE ACETONIDE BO
13925050820 FLUOCINOLONE ACETONIDE EA
13925050704 FLUOCINOLONE ACETONIDE SC
00093026415 FLUOCINONIDE
00168013460 FLUOCINONIDE
00472390160 FLUOCINONIDE
51672125301 FLUOCINONIDE
51672126403 FLUOCINONIDE
51672127901 FLUOCINONIDE
31722090405 FLUOXETINE HCL
49884033601 FLUOXETINE HCL
45802022211 FLUTICASONE PROPIONATE
00054329446 FUROSEMIDE
00603373921 FUROSEMIDE
42582011518 GABAPENTIN
43386006019 GAVILYTE-C
61442011501 GLIMEPIRIDE
00093834301 GLYBURIDE
00093943301 GLYBURIDE
00378106101 GUANFACINE ER
10370053301 GUANFACINE ER
24979053601 GUANFACINE ER
00378021401 HALOPERIDOL
00378035101 HALOPERIDOL
54799043105 HOMATROPINE HBR
64376064801 HYDROCODONE BITARTRATE/AC
00406012310 HYDROCODONE/ACETAMINOPHEN
00406012410 HYDROCODONE/ACETAMINOPHEN
00603388721 HYDROCODONE/ACETAMINOPHEN
00603389128 HYDROCODONE/ACETAMINOPHEN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
96 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
13107002001 HYDROCODONE/ACETAMINOPHEN
27808003503 HYDROCODONE/ACETAMINOPHEN
42858020101 HYDROCODONE/ACETAMINOPHEN
42858020201 HYDROCODONE/ACETAMINOPHEN
43386035701 HYDROCODONE/ACETAMINOPHEN
53746014501 HYDROCODONE/IBUPROFEN
45802093726 HYDROCORTISONE
62559043130 HYDROCORTISONE
00574709012 HYDROCORTISONE ACETATE
42582070101 HYDROCORTISONE ACETATE/PR
45802014464 HYDROCORTISONE ACETATE/PR
00713066815 HYDROCORTISONE VALERATE
00713066937 HYDROCORTISONE VALERATE
45802045537 HYDROCORTISONE VALERATE
51672129001 HYDROCORTISONE VALERATE
00054026425 HYDROMORPHONE HCL
13107010701 HYDROMORPHONE HCL
00093506101 HYDROXYZINE HCL
10702001110 HYDROXYZINE HCL
68462035305 HYDROXYZINE HCL
76439030810 HYOSCYAMINE SULFATE
00904585540 IBUPROFEN
55111068301 IBUPROFEN
67877032101 IBUPROFEN
00065175014 ILEVRO
68462040610 INDOMETHACIN
10147170003 ITRACONAZOLE
00832121710 JANTOVEN
00591060601 LABETALOL HCL
43199003701 LABETALOL HCL
50383077932 LACTULOSE
60432003732 LACTULOSE
29300011101 LAMOTRIGINE
51672413204 LAMOTRIGINE
66993042485 LANTHANUM CARBONATE
51991075933 LETROZOLE
50383024116 LEVETIRACETAM
43547034506 LEVETIRACETAM ER
68180011707 LEVETIRACETAM ER
60758006005 LEVOBUNOLOL HCL
50383028616 LEVOFLOXACIN
68180024101 LEVOFLOXACIN
69097028781 LEVOFLOXACIN
00378905593 LIDOCAINE
52565000814 LIDOCAINE
68462041827 LIDOCAINE
00603420921 LISINOPRIL
00603421021 LISINOPRIL
00185710001 LISINOPRIL/HYDROCHLOROTHI
00591086201 LISINOPRIL/HYDROCHLOROTHI
00781537101 LORAZEPAM
65162068784 LORAZEPAM
31722070190 LOSARTAN POTASSIUM
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
97 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
43547036050 LOSARTAN POTASSIUM
00185007201 LOVASTATIN
00054354258 MEGESTROL ACETATE
69076091302 MERCAPTOPURINE
54092010001 MESALAMINE DR
00185044801 METAXALONE
62037057110 METFORMIN HCL ER
27437005056 METHERGINE
00406114201 METHYLPHENIDATE HCL
00781574901 METHYLPHENIDATE HCL
43386057301 METHYLPHENIDATE HCL
00378815601 METHYLPHENIDATE HCL ER
13811070610 METHYLPHENIDATE HCL ER
00781502201 METHYLPREDNISOLONE
00093220405 METOCLOPRAMIDE HCL
42543000310 METOPROLOL TARTRATE
51672529509 METRONIDAZOLE
00093874001 MEXILETINE HCL
00185014901 MIDODRINE HCL
00245021111 MIDODRINE HCL
00591569550 MINOCYCLINE HCL
13668048405 MINOCYCLINE HCL
00115165308 MIRTAZAPINE ODT
60505252603 MODAFINIL
00713070185 MOMETASONE FUROATE
55111072530 MONTELUKAST SODIUM
69452010519 MONTELUKAST SODIUM
00054040444 MORPHINE SULFATE
42858080301 MORPHINE SULFATE ER
51862018501 MORPHINE SULFATE ER
63304045001 MORPHINE SULFATE ER
68382090501 MORPHINE SULFATE ER
65862060330 MOXIFLOXACIN HCL
51672131201 MUPIROCIN
00054016625 MYCOPHENOLATE MOFETIL
67877022505 MYCOPHENOLATE MOFETIL
00115165801 NABUMETONE
00781118101 NADOLOL
49483061801 NAPROXEN
65162018911 NAPROXEN
69097085407 NAPROXEN
00363019602 NICOTINE TRANSDERMAL SYST
43598044770 NICOTINE TRANSDERMAL SYST
65162047810 NITROFURANTOIN MONOHYDRAT
68001000100 NITROFURANTOIN MONOHYDRAT
43598043501 NITROGLYCERIN
68462030450 NORETHINDRONE ACETATE
68462065629 NORETHINDRONE ACETATE/ETH
00085432402 NOXAFIL
00832046560 NYAMYC
39822301506 NYSTATIN
51672128901 NYSTATIN
68308015230 NYSTATIN
68308015260 NYSTATIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
98 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
64980051501 OFLOXACIN
00093577001 OLANZAPINE
66993068530 OLANZAPINE
60505084505 OLOPATADINE HCL
70069000701 OLOPATADINE HCL
62756013101 ONDANSETRON HCL
62756018388 OXCARBAZEPINE
00093520601 OXYBUTYNIN CHLORIDE ER
42858000201 OXYCODONE HCL
13107004601 OXYCODONE/ACETAMINOPHEN
31722019205 OXYCODONE/ACETAMINOPHEN
00591369430 PALIPERIDONE ER
43547035003 PAROXETINE HCL
00065033230 PATANASE
10572030201 PEG-3350/NACL/NA BICARBON
00781120501 PENICILLIN V POTASSIUM
00126027116 PERIOGARD
00527131301 PILOCARPINE HYDROCHLORIDE
00093075601 PIROXICAM
00006494300 PNEUMOVAX 23/1 DOSE
00093406801 PRAZOSIN HCL
64764054311 PREVACID SOLUTAB
00603537128 PRIMIDONE
00008122214 PRISTIQ
00008122230 PRISTIQ
00378510501 PROCHLORPERAZINE MALEATE
62484002001 PURIXAN
00310828360 QUETIAPINE FUMARATE ER
68180058901 RAMIPRIL
59572042521 REVLIMID
59148004013 REXULTI
00781730431 RIVASTIGMINE TRANSDERMAL
67877026218 RIZATRIPTAN BENZOATE
65862062690 RIZATRIPTAN BENZOATE ODT
00054012025 ROPINIROLE HCL
47335058281 ROSUVASTATIN CALCIUM
16714061306 SERTRALINE HCL
59762490005 SERTRALINE HCL
57894007001 SIMPONI
49348014446 SM NICOTINE TRANSDERMAL S
00487900760 SODIUM CHLORIDE
42808011306 SODIUM SULFACETAMIDE/SULF
00299382345 SOOLANTRA
53489014401 SPIRONOLACTONE/HYDROCHLOR
61314070101 SULFACETAMIDE SODIUM
50383082416 SULFAMETHOXAZOLE/TRIMETHO
42806001101 SULINDAC
42806001801 SULINDAC
47335027641 SUMATRIPTAN SUCCINATE
62756052188 SUMATRIPTAN SUCCINATE
62756052288 SUMATRIPTAN SUCCINATE
45802070002 TACROLIMUS
00004080085 TAMIFLU
51672137302 TAZAROTENE
51672137303 TAZAROTENE
60758056130 TAZAROTENE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
99 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00228207610 TEMAZEPAM
00228207710 TEMAZEPAM
67877014930 TEMAZEPAM
16714050102 TERBINAFINE HCL
00832112035 TESTOSTERONE
62756001740 TESTOSTERONE CYPIONATE
61314022605 TIMOLOL MALEATE
64980051305 TIMOLOL MALEATE
59762004802 TOLTERODINE TARTRATE ER
69097012503 TOPIRAMATE
10019055301 TRANSDERM-SCOP
00574220120 TRETINOIN
43478024220 TRETINOIN
43478024320 TRETINOIN
00168000380 TRIAMCINOLONE ACETONIDE
00603786174 TRIAMCINOLONE ACETONIDE
45802004935 TRIAMCINOLONE ACETONIDE
45802006336 TRIAMCINOLONE ACETONIDE
52565001159 TRIAMCINOLONE ACETONIDE
64764073030 TRINTELLIX
00310080039 TUDORZA PRESSAIR
59746032537 VALACYCLOVIR HCL
65162030209 VENLAFAXINE HCL
00591288401 VERAPAMIL HCL SR
00074304153 VICODIN
42291026601 VITAMIN D
59417010110 VYVANSE
65162076810 WARFARIN SODIUM
29300013101 ZALEPLON
66582041431 ZETIA
00781531710 ZOLPIDEM TARTRATE
13668000801 ZOLPIDEM TARTRATE
68462043518 ACAMPROSATE CALCIUM DR
00603233832 ACETAMINOPHEN/CODEINE
00517760425 ACETYLCYSTEINE
00093894305 ACYCLOVIR
00093894705 ACYCLOVIR
42546072045 ADAPALENE
33332001601 AFLURIA PF 2016-2017
33332001701 AFLURIA PF 2017-2018
00378699152 ALBUTEROL SULFATE
00487990401 ALBUTEROL SULFATE
00487990425 ALBUTEROL SULFATE
00591379760 ALBUTEROL SULFATE
50383074016 ALBUTEROL SULFATE
00228202750 ALPRAZOLAM
00781108901 ALPRAZOLAM
59762371901 ALPRAZOLAM
59762372001 ALPRAZOLAM
00228308306 ALPRAZOLAM ER
00832011150 AMANTADINE HCL
51672402504 AMIODARONE HCL
16714044601 AMITRIPTYLINE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
100 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00603211032 AMLODIPINE BESYLATE
68645044470 AMLODIPINE BESYLATE
68645044570 AMLODIPINE BESYLATE
69097012615 AMLODIPINE BESYLATE
76282023890 AMLODIPINE BESYLATE
55111033901 AMLODIPINE BESYLATE/BENAZ
00093415579 AMOXICILLIN
00143988815 AMOXICILLIN
00143988915 AMOXICILLIN
00781202001 AMOXICILLIN
00781202005 AMOXICILLIN
00781506120 AMOXICILLIN
00781604146 AMOXICILLIN
16714029801 AMOXICILLIN
42582021418 AMOXICILLIN
57237003101 AMOXICILLIN
57237003301 AMOXICILLIN
65862001701 AMOXICILLIN
00143985316 AMOXICILLIN/CLAVULANATE P
16714029303 AMOXICILLIN/CLAVULANATE P
16714029403 AMOXICILLIN/CLAVULANATE P
60432006547 AMOXICILLIN/CLAVULANATE P
65862053401 AMOXICILLIN/CLAVULANATE P
66685101200 AMOXICILLIN/CLAVULANATE P
00185086401 AMPHETAMINE/DEXTROAMPHETA
00378454501 AMPHETAMINE/DEXTROAMPHETA
00406889301 AMPHETAMINE/DEXTROAMPHETA
00555077502 AMPHETAMINE/DEXTROAMPHETA
57664064608 AMPHETAMINE/DEXTROAMPHETA
00713050312 ANUCORT-HC
00093761356 ARIPIPRAZOLE
13668021830 ARIPIPRAZOLE
27241005303 ARIPIPRAZOLE
43598055430 ARIPIPRAZOLE
43598055930 ARIPIPRAZOLE
65162089703 ARIPIPRAZOLE
00085146102 ASMANEX TWISTHALER 30 MET
00093354456 ATOMOXETINE
64980037503 ATOMOXETINE
66993004130 ATOMOXETINE
65162069388 ATOVAQUONE
66993006027 ATOVAQUONE/PROGUANIL HCL
00472038245 AUGMENTED BETAMETHASONE D
45802037635 AUGMENTED BETAMETHASONE D
68462029017 AUGMENTED BETAMETHASONE D
51991081403 AZELASTINE HCL
00023869430 AZELEX
00781149631 AZITHROMYCIN
00781577626 AZITHROMYCIN
00781577631 AZITHROMYCIN
60505258100 AZITHROMYCIN
64380071307 BENZONATATE
65162053650 BENZONATATE
65162053710 BENZONATATE
67877010501 BENZONATATE
68382024705 BENZONATATE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
101 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
69452014330 BENZONATATE
00603243521 BENZTROPINE MESYLATE
00832108000 BENZTROPINE MESYLATE
00472037115 BETAMETHASONE VALERATE
00378052401 BISOPROLOL FUMARATE
29300012613 BISOPROLOL FUMARATE
58160084211 BOOSTRIX
24208041105 BRIMONIDINE TARTRATE
00093681573 BUDESONIDE
00487960130 BUDESONIDE
00378114501 BUSPIRONE HCL
68382018105 BUSPIRONE HCL
43199005301 BUTALBITAL/ACETAMINOPHEN
00591264001 BUTALBITAL/ACETAMINOPHEN/
51991007301 BUTALBITAL/ACETAMINOPHEN/
51672415403 CALCIPOTRIENE
51672415404 CALCIPOTRIENE
45802098996 CALCIPOTRIENE/BETAMETHASO
13668027101 CARBAMAZEPINE
00378008801 CARBIDOPA/LEVODOPA ER
00093413764 CEFDINIR
65862021801 CEFDINIR
67253001342 CEFDINIR
68001015006 CEFDINIR
68180040201 CEFPROZIL
68180040202 CEFPROZIL
68180040301 CEFPROZIL
16714040001 CEFUROXIME AXETIL
16714040002 CEFUROXIME AXETIL
65862070020 CEFUROXIME AXETIL
67877021520 CEFUROXIME AXETIL
67877021560 CEFUROXIME AXETIL
00378715005 CELECOXIB
00378716001 CELECOXIB
59762151701 CELECOXIB
00093417573 CEPHALEXIN
68180044101 CEPHALEXIN
68180044102 CEPHALEXIN
00555015802 CHLORDIAZEPOXIDE HCL
00832030000 CHLORPROMAZINE HCL
00574206101 CICLOPIROX
51672131808 CICLOPIROX OLAMINE
68462029792 CICLOPIROX OLAMINE
00065065435 CILOXAN
50419077301 CIPRO
50419077701 CIPRO
00172531360 CIPROFLOXACIN HCL
16252051605 CIPROFLOXACIN HCL
16571012025 CIPROFLOXACIN HCL
16571041250 CIPROFLOXACIN HCL
55111012850 CIPROFLOXACIN HCL
61442022305 CIPROFLOXACIN HCL
31722020705 CITALOPRAM HYDROBROMIDE
42806002010 CITALOPRAM HYDROBROMIDE
65162005203 CITALOPRAM HYDROBROMIDE
00555105486 CLARAVIS
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
102 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00781196260 CLARITHROMYCIN
59746074360 CLARITHROMYCIN
59762332801 CLINDAMYCIN HCL
59762501001 CLINDAMYCIN HCL
16714048301 CLINDAMYCIN PALMITATE HCL
45802056201 CLINDAMYCIN PHOSPHATE
45802050701 CLINDAMYCIN/BENZOYL PEROX
00168016360 CLOBETASOL PROPIONATE
00168026950 CLOBETASOL PROPIONATE
00472040015 CLOBETASOL PROPIONATE
00713065660 CLOBETASOL PROPIONATE
40085088800 CLOBETASOL PROPIONATE
45802043733 CLOBETASOL PROPIONATE
45802092594 CLOBETASOL PROPIONATE
51672129401 CLOBETASOL PROPIONATE
60429090130 CLOBETASOL PROPIONATE
50383027030 CLOBETASOL PROPIONATE EMO
00093083310 CLONAZEPAM
16714075001 CLONAZEPAM
16729013600 CLONAZEPAM
00228212910 CLONIDINE HCL
00378087199 CLONIDINE HCL
62332005471 CLONIDINE HCL
62332005491 CLONIDINE HCL
00093777205 CLOZAPINE
00054024425 CODEINE SULFATE
00527169801 CODEINE SULFATE
64764011907 COLCRYS
50458058601 CONCERTA
52544004513 CONDYLOX
00378076101 CYCLOBENZAPRINE HCL
00603307821 CYCLOBENZAPRINE HCL
10702000610 CYCLOBENZAPRINE HCL
10702000710 CYCLOBENZAPRINE HCL
31722028301 CYCLOBENZAPRINE HCL
65162054110 CYCLOBENZAPRINE HCL
52817021010 CYPROHEPTADINE HCL
49938010130 DAPSONE
51672138703 DAPSONE
40076062405 DENAVIR
45963034202 DESIPRAMINE HCL
00093731701 DESMOPRESSIN ACETATE
68462027501 DESMOPRESSIN ACETATE
68462027601 DESMOPRESSIN ACETATE
00472080302 DESONIDE
45802042337 DESONIDE
45802049535 DESOXIMETASONE
00378423093 DESVENLAFAXINE ER
00591365930 DESVENLAFAXINE ER
68180059206 DESVENLAFAXINE ER
00054317763 DEXAMETHASONE
00054317644 DEXAMETHASONE INTENSOL
55150023701 DEXAMETHASONE SODIUM PHOS
43386086101 DEXMETHYLPHENIDATE HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
103 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00093555001 DEXMETHYLPHENIDATE HCL ER
00115168201 DEXMETHYLPHENIDATE HCL ER
51862034590 DEXTROAMPHETAMINE SULFATE
00093613732 DIAZEPAM
00093613832 DIAZEPAM
00527176836 DIAZEPAM
00603321521 DIAZEPAM
51862006405 DIAZEPAM
51862006410 DIAZEPAM
00093094801 DICLOFENAC POTASSIUM
00781178701 DICLOFENAC SODIUM DR
00781178905 DICLOFENAC SODIUM DR
00781178910 DICLOFENAC SODIUM DR
61442010305 DICLOFENAC SODIUM DR
00527058610 DICYCLOMINE HCL
00527128201 DICYCLOMINE HCL
00591079510 DICYCLOMINE HCL
00603116158 DICYCLOMINE HCL
52015008001 DIFICID
49884082905 DILTIAZEM CD
49884082911 DILTIAZEM CD
68682099898 DILTIAZEM HCL ER
55111053401 DIVALPROEX SODIUM ER
65162075510 DIVALPROEX SODIUM ER
68382031401 DIVALPROEX SODIUM ER
43547027603 DONEPEZIL HCL
60432065104 DOXEPIN HCL
00143314250 DOXYCYCLINE HYCLATE
69238110005 DOXYCYCLINE HYCLATE
00591041150 DOXYCYCLINE MONOHYDRATE
00228289203 DULOXETINE HCL
31722058230 DULOXETINE HCL
60505387703 DUTASTERIDE
51672130301 ECONAZOLE NITRATE
52565002285 ECONAZOLE NITRATE
59762232101 ELETRIPTAN HYDROBROMIDE
50102091101 ELLA
00603754049 EMOQUETTE
16714044201 ENALAPRIL MALEATE
64679092302 ENALAPRIL MALEATE
68645045690 ENALAPRIL MALEATE
60951060270 ENDOCET
60951071270 ENDOCET
00703851023 ENOXAPARIN SODIUM
62037086620 ENOXAPARIN SODIUM
00078065967 ENTRESTO
00078069620 ENTRESTO
00078077767 ENTRESTO
49035019502 EQ NICOTINE
24338012213 ERY-TAB
24338010620 ERYTHROCIN STEARATE
45802003846 ERYTHROMYCIN
60432067160 ERYTHROMYCIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
104 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00093585101 ESCITALOPRAM OXALATE
00378385610 ESCITALOPRAM OXALATE
68001019600 ESCITALOPRAM OXALATE
00378145405 ESTRADIOL
00054029225 ESZOPICLONE
00378527201 ESZOPICLONE
68462038301 ESZOPICLONE
68180028101 ETHAMBUTOL HCL
00185068701 ETODOLAC
51672401801 ETODOLAC
51672403601 ETODOLAC
60505004101 ETODOLAC
00781569005 EZETIMIBE
16714061601 FAMCICLOVIR
61442012201 FAMOTIDINE
23155005001 FELODIPINE ER
00115551110 FENOFIBRATE
00378912298 FENTANYL
00378912598 FENTANYL
00591321272 FENTANYL
00591321472 FENTANYL
47781042347 FENTANYL
47781042447 FENTANYL
60505700702 FENTANYL
57237006230 FINASTERIDE
65862014930 FINASTERIDE
00172541146 FLUCONAZOLE
00172541211 FLUCONAZOLE
00172541360 FLUCONAZOLE
16714069302 FLUCONAZOLE
16714069601 FLUCONAZOLE
55111014571 FLUCONAZOLE
67405060403 FLUCONAZOLE
68462010230 FLUCONAZOLE
16714050201 FLUOCINONIDE
51672125302 FLUOCINONIDE
51672127302 FLUOCINONIDE
51862049415 FLUOCINONIDE
00378479106 FLUOROURACIL
51672406301 FLUOROURACIL
66530025830 FLUOROURACIL
49884033511 FLUOXETINE HCL
45802022135 FLUTICASONE PROPIONATE
45802022237 FLUTICASONE PROPIONATE
70461011902 FLUVIRIN 2016-2017
49281062515 FLUZONE QUADRIVALENT 2016
54092025290 FOSRENOL
54092025490 FOSRENOL
00603374021 FUROSEMIDE
67877022201 GABAPENTIN
67877022210 GABAPENTIN
67877022301 GABAPENTIN
67877022401 GABAPENTIN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
105 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
61314067225 GATIFLOXACIN
00713068331 GENTAMICIN SULFATE
61314063305 GENTAMICIN SULFATE
52268010001 GOLYTELY
64980018603 GRISEOFULVIN MICROSIZE
64720029610 GRISEOFULVIN ULTRAMICROSI
00093596001 GUANFACINE ER
00093596101 GUANFACINE ER
00591044401 GUANFACINE HCL
68382007901 HALOPERIDOL
58160082611 HAVRIX
63323026201 HEPARIN SODIUM
00074433906 HUMIRA PEN-CROHNS DISEASE
50111039801 HYDRALAZINE HCL
50111039803 HYDRALAZINE HCL
00406037605 HYDROCODONE BITARTRATE/AC
00406012505 HYDROCODONE/ACETAMINOPHEN
00603389028 HYDROCODONE/ACETAMINOPHEN
27808003501 HYDROCODONE/ACETAMINOPHEN
27808003502 HYDROCODONE/ACETAMINOPHEN
27808003601 HYDROCODONE/ACETAMINOPHEN
42858020150 HYDROCODONE/ACETAMINOPHEN
42858020301 HYDROCODONE/ACETAMINOPHEN
42858020350 HYDROCODONE/ACETAMINOPHEN
51862022705 HYDROCODONE/ACETAMINOPHEN
51862022801 HYDROCODONE/ACETAMINOPHEN
57664012688 HYDROCODONE/ACETAMINOPHEN
57664017688 HYDROCODONE/ACETAMINOPHEN
65162011550 HYDROCODONE/ACETAMINOPHEN
45802000402 HYDROCORTISONE
62559013807 HYDROCORTISONE
45802012464 HYDROCORTISONE ACETATE/PR
00713066837 HYDROCORTISONE VALERATE
45802045535 HYDROCORTISONE VALERATE
45802045542 HYDROCORTISONE VALERATE
51672129201 HYDROCORTISONE VALERATE
42858030201 HYDROMORPHONE HCL
00781140797 HYDROXYCHLOROQUINE SULFAT
16714008310 HYDROXYZINE HCL
23155050105 HYDROXYZINE HCL
60432015016 HYDROXYZINE HCL
00115167002 HYDROXYZINE PAMOATE
00555032304 HYDROXYZINE PAMOATE
51525011501 HYOSCYAMINE SULFATE ER
42192033801 HYOSCYAMINE SULFATE ODT
53746046401 IBUPROFEN
68645052990 IBUPROFEN
68382029401 INDOMETHACIN
00487020101 IPRATROPIUM BROMIDE/ALBUT
69097017353 IPRATROPIUM BROMIDE/ALBUT
69097017364 IPRATROPIUM BROMIDE/ALBUT
35573031110 ISOMETHEPTENE/DICHLORALPH
58657040101 ISOMETHEPTENE/DICHLORALPH
68382065001 ISOSORBIDE MONONITRATE ER
68382065105 ISOSORBIDE MONONITRATE ER
00832121100 JANTOVEN
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
106 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00597014660 JENTADUETO
51672402601 KETOCONAZOLE
00574200216 KIONEX
50383079516 LACTULOSE
00228142203 LAMOTRIGINE ER
00228145303 LAMOTRIGINE ER
16714035501 LEVETIRACETAM
16714035502 LEVETIRACETAM
43547022115 LEVETIRACETAM
43547022211 LEVETIRACETAM
00781579220 LEVOFLOXACIN
69097028270 LEVOFLOXACIN
76329301305 LIDOCAINE HCL JELLY
00591040801 LISINOPRIL
00904648580 LISINOPRIL
68001020700 LISINOPRIL
76282042090 LISINOPRIL
00054452725 LITHIUM CARBONATE
00054002025 LITHIUM CARBONATE ER
00121077001 LORAZEPAM
00603424732 LORAZEPAM
69315090501 LORAZEPAM
69315090601 LORAZEPAM
52544094928 LUTERA
00555060702 MEGESTROL ACETATE
49884029001 MEGESTROL ACETATE
49884029004 MEGESTROL ACETATE
49884090738 MEGESTROL ACETATE
60432012608 MEGESTROL ACETATE
00078066815 MEKINIST
54458096416 MELOXICAM
54458096510 MELOXICAM
61442012701 MELOXICAM
61442012710 MELOXICAM
00187170405 MEPHYTON
62559042007 MESALAMINE
68382071119 MESALAMINE DR
67877056305 METFORMIN HCL
00603448621 METHOCARBAMOL
00603457621 METHYLPHENIDATE HCL
31722017401 METHYLPHENIDATE HCL
00093529301 METHYLPHENIDATE HCL CD
62175015337 METHYLPHENIDATE HCL CD
00378815777 METHYLPHENIDATE HCL ER
00781236201 METHYLPHENIDATE HCL ER
00603459321 METHYLPREDNISOLONE
59762005001 METHYLPREDNISOLONE
00591046210 METOPROLOL TARTRATE
42543000110 METOPROLOL TARTRATE
00591252101 METRONIDAZOLE
23155006501 METRONIDAZOLE
29300022652 METRONIDAZOLE
75834010805 METRONIDAZOLE
52544029021 MICROGESTIN 1.5/30
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
107 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00115422201 MIDODRINE HCL
00245021211 MIDODRINE HCL
63304069401 MINOCYCLINE HCL
65862021105 MINOCYCLINE HCL
16714070801 MIRTAZAPINE
60505024908 MIRTAZAPINE
43386016101 MISOPROSTOL
00006468100 M-M-R II
00713070153 MOMETASONE FUROATE
45802011859 MOMETASONE FUROATE
68462022555 MOMETASONE FUROATE
00093742598 MONTELUKAST SODIUM
00603465528 MONTELUKAST SODIUM
00781556031 MONTELUKAST SODIUM
31722072830 MONTELUKAST SODIUM
68001024803 MONTELUKAST SODIUM
00054023763 MORPHINE SULFATE
00406800330 MORPHINE SULFATE
00406833001 MORPHINE SULFATE ER
51862018601 MORPHINE SULFATE ER
60951065270 MORPHINE SULFATE ER
68382090401 MORPHINE SULFATE ER
55111011230 MOXIFLOXACIN HCL
57237015630 MOXIFLOXACIN HCL
68180085211 MY WAY
16729001916 MYCOPHENOLATE MOFETIL
61748030113 MYORISAN
61748030411 MYORISAN
69097086807 NADOLOL
51224020650 NALTREXONE HCL
53746019001 NAPROXEN
65162018810 NAPROXEN
65162018910 NAPROXEN
69097085507 NAPROXEN
31722033901 NAPROXEN DR
69097085207 NAPROXEN DR
42043013109 NARATRIPTAN HCL
55513053010 NEUPOGEN
55513092410 NEUPOGEN
50474080203 NEUPRO
52544006554 NEXT CHOICE ONE DOSE
00363918002 NICOTINE TRANSDERMAL SYST
43598044874 NICOTINE TRANSDERMAL SYST
00281032630 NITRO-BID
00281032660 NITRO-BID
00378170001 NITROFURANTOIN MACROCRYST
00378910293 NITROGLYCERIN TRANSDERMAL
64597030160 NUEDEXTA
00603781874 NYSTATIN
00713067815 NYSTATIN
43386053002 NYSTATIN
43386053006 NYSTATIN
60432053760 NYSTATIN
00093576810 OLANZAPINE
00093576956 OLANZAPINE
33342007107 OLANZAPINE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
108 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
62756055283 OLANZAPINE
00781279092 OMEPRAZOLE
55111015901 OMEPRAZOLE
68462039701 OMEPRAZOLE
57237007630 ONDANSETRON HCL
00781523980 ONDANSETRON ODT
53885059501 ONETOUCH DELICA LANCETS F
47781038426 OSELTAMIVIR PHOSPHATE
59572063255 OTEZLA
51991029305 OXCARBAZEPINE
51991029401 OXCARBAZEPINE
00603149158 OXYBUTYNIN CHLORIDE
00603497532 OXYBUTYNIN CHLORIDE
16729031801 OXYBUTYNIN CHLORIDE ER
10702001850 OXYCODONE HCL
47781026305 OXYCODONE HCL
62559015116 OXYCODONE HCL
66689040316 OXYCODONE HCL
68462034737 OXYCODONE HCL
00781570301 OXYCODONE HCL ER
63304068401 OXYCODONE HCL ER
31722019301 OXYCODONE/ACETAMINOPHEN
47781022901 OXYCODONE/ACETAMINOPHEN
47781023001 OXYCODONE/ACETAMINOPHEN
68308084501 OXYCODONE/ASPIRIN
10147095303 PALIPERIDONE ER
52376002102 PAROEX
00378700493 PAROXETINE HCL
57237004199 PENICILLIN V POTASSIUM
67253020150 PENICILLIN V POTASSIUM
00591299239 PHENADOZ
42937070210 PHENAZOPYRIDINE HCL
58657045101 PHENAZOPYRIDINE HCL
51285016288 PLAN B ONE-STEP
00006483702 PNEUMOVAX 23
00023782410 POLYTRIM
76439034330 POTASSIUM CHLORIDE
62037099910 POTASSIUM CHLORIDE ER
68382070101 POTASSIUM CHLORIDE ER
13668009190 PRAMIPEXOLE DIHYDROCHLORI
68382019716 PRAMIPEXOLE DIHYDROCHLORI
00603156756 PREDNISOLONE
13925016604 PREDNISOLONE SODIUM PHOSP
24208071510 PREDNISOLONE SODIUM PHOSP
00054472825 PREDNISONE
00591544205 PREDNISONE
00603533621 PREDNISONE
00603533815 PREDNISONE
00046110181 PREMARIN
00046110481 PREMARIN
55566930002 PREPOPIK
00126001661 PREVIDENT 5000 DRY MOUTH
00713013512 PROCHLORPERAZINE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
109 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
59746011306 PROCHLORPERAZINE MALEATE
00603543721 PROMETHAZINE HCL
45802075930 PROMETHAZINE HCL
57664010888 PROMETHAZINE HCL
68382004001 PROMETHAZINE HCL
00603158654 PROMETHAZINE-DM
00115166202 PROPRANOLOL HCL
00378018301 PROPRANOLOL HCL
50111046903 PROPRANOLOL HCL
00228277811 PROPRANOLOL HCL ER
43478090188 PROPRANOLOL HCL ER
00228234810 PROPYLTHIOURACIL
47781033530 PYRIDOSTIGMINE BROMIDE ER
00054022125 QUETIAPINE FUMARATE
00093816301 QUETIAPINE FUMARATE
00093816501 QUETIAPINE FUMARATE
60505313301 QUETIAPINE FUMARATE
68180044907 QUETIAPINE FUMARATE
68180045001 QUETIAPINE FUMARATE
49884080602 QUETIAPINE FUMARATE ER
00781188425 RANITIDINE HCL
00378350505 RISPERIDONE
68382011505 RISPERIDONE
33342008872 RIZATRIPTAN BENZOATE
67877026118 RIZATRIPTAN BENZOATE
43547026810 ROPINIROLE HCL
00378220477 ROSUVASTATIN CALCIUM
13668018090 ROSUVASTATIN CALCIUM
68462026390 ROSUVASTATIN CALCIUM
64764080510 ROZEREM
51293080301 SALSALATE
16714061106 SERTRALINE HCL
16714061204 SERTRALINE HCL
31722021205 SERTRALINE HCL
59762490001 SERTRALINE HCL
59762496001 SERTRALINE HCL
00591081055 SILVER SULFADIAZINE
67877012420 SILVER SULFADIAZINE
67877012425 SILVER SULFADIAZINE
67877012450 SILVER SULFADIAZINE
16729000415 SIMVASTATIN
00378698501 SODIUM CHLORIDE
00378698601 SODIUM CHLORIDE
10702003645 SODIUM POLYSTYRENE SULFON
44523060201 SODIUM SULFACETAMIDE/SULF
00009001103 SOLU-CORTEF
53489032901 SPIRONOLACTONE
65162051510 SPIRONOLACTONE
43598021025 SSD
43598021050 SSD
43598021085 SSD
00245000331 SSKI
12496120403 SUBOXONE
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
110 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
59762040105 SUCRALFATE
63739094310 SUCRALFATE
42808011006 SULFACETAMIDE SODIUM/SULF
16714053111 SUMATRIPTAN SUCCINATE
50222050106 TACLONEX
00378250010 TAMSULOSIN HCL
00023004210 TAZORAC
64406000703 TECFIDERA STARTER PACK
00378401005 TEMAZEPAM
00603589421 TEMAZEPAM
67877014605 TEMAZEPAM
00781269275 TEMOZOLOMIDE
00781269444 TEMOZOLOMIDE
59746038406 TERAZOSIN HCL
00832112005 TESTOSTERONE
00591292102 TESTOSTERONE PUMP
13533013101 TETANUS/DIPHTHERIA TOXOID
23155001801 TETRACYCLINE HCL
59572020514 THALOMID
57664050389 TIZANIDINE HCL
24208029525 TOBRAMYCIN/DEXAMETHASONE
61314064725 TOBRAMYCIN/DEXAMETHASONE
13668018990 TOLTERODINE TARTRATE ER
47335085983 TRAMADOL HCL ER
00067434504 TRANSDERM-SCOP
10019055302 TRANSDERM-SCOP
00603616021 TRAZODONE HCL
60505265405 TRAZODONE HCL
00574220520 TRETINOIN
00574222520 TRETINOIN
43478024120 TRETINOIN
66530025520 TRETINOIN
66530025715 TRETINOIN
66530026245 TRETINOIN
00168000315 TRIAMCINOLONE ACETONIDE
00168000580 TRIAMCINOLONE ACETONIDE
00603786190 TRIAMCINOLONE ACETONIDE
45802006335 TRIAMCINOLONE ACETONIDE
51672128401 TRIAMCINOLONE ACETONIDE
68462079817 TRIAMCINOLONE ACETONIDE
00093215801 TRIMETHOPRIM
00005010005 TRUMENBA
00378427677 VALACYCLOVIR HCL
16714069803 VALACYCLOVIR HCL
69097015412 VALACYCLOVIR HCL
55111076260 VALGANCICLOVIR
47781072902 VANCOMYCIN HCL
59762018002 VENLAFAXINE HCL ER
65862052790 VENLAFAXINE HCL ER
00173068221 VENTOLIN HFA
00173068224 VENTOLIN HFA
00591034301 VERAPAMIL HCL
23155002701 VERAPAMIL HCL
DRUG FORMULARY MATCH
RFP - HR1809 Medical Benefits
APPENDIX G-2
111 2/22/2018
National
Drug Code
(NDC)
Drug NameProposed Formulary Tier
(Member Copay Tier)
Is Prior Authorization
Required in Proposed
Formulary?
Is Step Therapy
Required in Proposed
Formulary?
Comments
00591288201 VERAPAMIL HCL SR
00069421030 VIAGRA
00093529056 VORICONAZOLE
57237012601 WARFARIN SODIUM
50458057890 XARELTO
65649030304 XIFAXAN
63402051001 XOPENEX HFA
00093526801 ZALEPLON
29300013201 ZALEPLON
68180033107 ZIPRASIDONE HCL
00378530505 ZOLPIDEM TARTRATE
00781531701 ZOLPIDEM TARTRATE
68180077901 ZOLPIDEM TARTRATE ER
62756026002 ZONISAMIDE
69097086107 ZONISAMIDE