21-Attachment Q - CoA De-ID High-Cost Claimants 08-2026.pdf

CITY OF AMARILLO

Year: 2026 (JAN-AUG) Unique Mbr Id De-

Identified Status_Relation_Age_Sex Medical Paid

Amount Pharmacy Paid

Amount Total Paid Primary Diagnosis Description Primary Rx

5576161182 Active_Spouse_50_F $ 797,200 $ 14,598 $ 811,798 C90.01 Plasma Cell Leukemia, A Rare And Aggressive Form Of Multiple Myeloma Characterized By Excessive Plasma Cells In The Peripheral Blood

POMALIDOMIDE

4726784013 RetU65_Subscriber_64_M 719,804$ 847$ 720,652$ C83.390 Primary Central Nervous System Lymphoma (Pcnsl) VALSARTAN

3546683232 Active_Child_6_F 247,182$ 52,398$ 299,580$ Q65.89 Congenital Deformities Of The Hip, Including Conditions Like Femoral Neck Anteversion And Congenital Acetabular Dysplasia

LUPRON DEPOT-PED (6-MONTH)

5366287766 Active_Child_12_M $ 9,906 $ 270,772 $ 280,678 E84.0 Cystic Fibrosis With Pulmonary Manifestations ALYFTREK, ZENPEP, PULMOZYME

7176955007 Active_Spouse_50_F $ 258,758 $ 978 $ 259,736 C53.0 Malignant Neoplasm Of The Endocervix, Meaning Cancer Originating In The Internal Lining Of The Cervical Canal

TROSPIUM CHLORIDE ER

4246225941 Active_Subscriber_71_M $ 242,705 $ 267 $ 242,972 I63.541 Cerebral Infarction Due To Unspecified Occlusion Or Stenosis Of Right Cerebellar Artery, CIPROFLOXACIN-DEXAMETHASONE

9686135117 RetU65_Spouse_58_F $ 211,167 $ 11,866 $ 223,033 K56.50 Intestinal Adhesions [Bands], Unspecified As To Partial Versus Complete Obstruction

BRIVARACETAM

4226876597 Active_Spouse_61_F $ 221,083 $ 305 $ 221,387 I35.0 Nonrheumatic Aortic Valve Stenosis, A Condition Where The Aortic Valve Narrows, Restricting Blood Flow From The Left Ventricle To The Aorta

WARFARIN SODIUM

1256115074 Active_Subscriber_49_F $ 194,314 $ 1,488 $ 195,802 C50.411 Malignant Neoplasm Of The Upper-Outer Quadrant Of The Right Female Breast

TRELEGY ELLIPTA

3366247857 Active_Child_17_M $ 180,923 $ 1,579 $ 182,502 S21.332A Puncture Wound Without Foreign Body Of Left Front Wall Of Thorax With Penetration Into Thoracic Cavity, Initial Encounter

DULOXETINE HCL

5886797315 Active_Spouse_47_F $ 2,048 $ 170,770 $ 172,818 N80.03, C50.811 Adenomyosis Of The Uterus, Malignant Neoplasm Of Overlapping Sites Of The Right Female Breast

VERZENIO

0836655277 Active_Spouse_78_F $ 172,147 $ 418 $ 172,565 C34.12 Malignant Neoplasm Of The Upper Lobe Of The Left Bronchus Or Lung SUCRALFATE

8236933179 Active_Spouse_63_M $ 19,434 $ 151,524 $ 170,958 C61 Malignant Neoplasm Of The Prostate XTANDI

8016592382 Active_Subscriber_28_M $ 163,053 $ 162 $ 163,215 C85.18 Unspecified B-Cell Lymphoma, Lymph Nodes Of Multiple Sites APREPITANT

3,439,724$ 677,972$ 4,117,696$

High Cost Claimants Listing Threshold: $150,000

Source: Aetna Catastrophic Detail (Medical) Maxor+ (Pharmacy), Eff 1/1/26: RxBenefits(Optum-Pharmacy) Page 1 of 4

CITY OF AMARILLO High Cost Claimants Listing Threshold: $150,000

Year: 2025 Unique Mbr Id De-

Identified Status_Relation_Age_Sex Medical Paid

Amount Pharmacy Paid

Amount Total Paid Primary Diagnosis Description Primary Rx

5366287766 Active_Child_11_M $ 22,040 $ 490,150 $ 512,190 E84.0 Cystic Fibrosis With Pulmonary Manifestations ALYFTREK, PULMOZYME, ZENPEP 6236059582 RetU65_Subscriber_62_M 450,322$ 3,686$ 454,009$ C17.0 Malignant Neoplasm Of The Duodenum; I26.99 Other Pulmonary Embolism

Without Acute Cor Pulmonale

XARELTO

9686135117 RetU65_Spouse_57_F 349,582$ 38,215$ 387,797$ K56.51 Intestinal Adhesions [Bands] With Partial Obstruction BRIVIACT, EMGALITY, LINZESS 3946161840 Active_Spouse_37_F $ 336,430 $ 5,500 $ 341,930 E27.1 Primary Adrenocortical Insufficiency GAMMAGARD 3546683232 Active_Child_5_F $ 258,038 $ 75,683 $ 333,722 G80.0 Spastic quadriplegic cerebral palsy LUPRON DEPOT

6986197302 Active_Subscriber_65_M $ 275,565 $ 6,909 $ 282,475 C15.4 Malignant Neoplasm Of The Middle Third Of The Esophagus ELIQUIS 5886797315 Active_Spouse_46_F $ 76,966 $ 183,470 $ 260,437 C50.811 Malignant Neoplasm Of Overlapping Sites Of The Right Female Breast VERZENIO

2336573600 Active_Subscriber_31_M $ 346 $ 258,589 $ 258,935 K29.50 Unspecified Chronic Gastritis Without Bleeding JYNARQUE 5576161182 Active_Spouse_49_F $ 171,194 $ 73,453 $ 244,646 C90.01 Multiple Myeloma In Remission POMALYST, PAXLOVID 3696650787 Active_Subscriber_59_F $ 216,381 $ 23,561 $ 239,942 M17.11, T84.53Xa Unilateral Primary Osteoarthritis, Right Knee, Infection And

Inflammatory Reaction Due To An Internal Right Knee Prosthesis During An Initial Encounter

BENLYSTA

5336524465 Active_Child_14_M $ 1,574 $ 202,355 $ 203,930 E25.0 Congenital Adrenogenital Disorders Associated With Enzyme Deficiency CRENESSITY

4476134253 Active_Subscriber_27_M $ 351 $ 197,643 $ 197,994 C92.10 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission

ICLUSIG

7176955007 Active_Spouse_49_F $ 197,259 $ 439 $ 197,698 C53.0 Malignant Tumor Located In The Endocervix FENTANYL 4726784013 RetU65_Subscriber_63_M $ 191,984 $ 2,729 $ 194,713 C83.390 Primary Central Nervous System Lymphoma TEMOZOLOMIDE 0326252525 RetU65_Subscriber_60_M $ 172,212 $ 13,367 $ 185,580 G61.81 Chronic Inflammatory Demyelinating Polyneuritis MOUNJARO 0096005888 Active_Spouse_36_F $ 13,573 $ 166,106 $ 179,679 C50.812 Malignant Neoplasm Of Overlapping Sites Of Left Female Breast LYNPARZA, VERZENIO

8946430669 Active_Subscriber_33_F $ 155,231 $ 820 $ 156,051 C49.4 Malignant Neoplasm Of Connective And Soft Tissue Of The Abdomen ELIQUIS

8546205278 Active_Spouse_38_F $ 4,142 $ 149,742 $ 153,884 L73.2 Hidradenitis Suppurativa COSENTYX UNO 7416215661 Active_Spouse_59_M $ 147,779 $ 1,143 $ 148,922 T81.49XA Infection Following A Procedure, Other Surgical Site, Initial Encounter TRELEGY, LINEZOLID

3,040,972$ 1,893,561$ 4,934,533$

Maxor+ (Pharmacy), Eff 1/1/26: RxBenefits(Optum-Pharmacy) Page 2 of 4

Year: 2024 Unique Mbr Id De-

Identified Status_Relation_Age_Sex Medical Paid

Amount Pharmacy Paid

Amount Total Paid Primary Diagnosis Description Primary Rx

5576161182 Active_Spouse_48_F 439,126$ 165$ 439,291$ C90.01 Multiple myeloma in remission ALBUTEROL 5366287766 Active_Child_10_M 21,333$ 388,160$ 409,494$ E84.0 Cystic fibrosis with pulmonary manifestations TRIKAFTA, ZENPEP, PULMOZYME 3496139616 Active_Subscriber_36_M 392,606$ 62$ 392,667$ Q25.43 Congenital aneurysm of aorta WARFARIN 0096005888 Active_Subscriber_55_M 113,464$ 162,461$ 275,924$ C50.912 Malignant neoplasm of unspecified site of left female breast LYNPARZA 2336573600 Active_Subscriber_30_M 2,379$ 251,328$ 253,707$ K29.50 Unspecified chronic gastritis without bleeding JYNARQUE 0336614701 Active_Subscriber_64_F 211,981$ 10,433$ 222,414$ C25.0 Malignant neoplasm of head of pancreas TERIFLUNOMID 2016288291 RetU65_Spouse_64_M 47,382$ 173,727$ 221,109$ M48.062 Spinal stenosis, lumbar region with neurogenic claudication STELARA 5166522043 Active_Child_1_F 196,058$ 343$ 196,400$ N13.70 Vesicoureteral-reflux, unspecified FAMOTIDINE 4006317357 RetU65_Spouse_60_F 181,775$ 11,023$ 192,799$ I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

NITAZOXANIDE

3896833837 RetU65_Subscriber_62_M 182,035$ 3,648$ 185,682$ G12.21 Amyotrophic lateral sclerosis; M48.02 Spinal stenosis, cervical region MONOVISC

5816142229 Active_Subscriber_71_M 9,891$ 147,712$ 157,602$ H35.3113 Nonexudative Age-related Macular Degeneration, Right Eye INREBIC, JAKAFI 1,798,029$ 1,149,061$ 2,947,090$

Maxor+ (Pharmacy), Eff 1/1/26: RxBenefits(Optum-Pharmacy) Page 3 of 4

Year: 2023 Unique Mbr Id De-

Identified Status_Relation_Age_Sex Medical Paid

Amount Pharmacy Paid

Amount Total Paid Primary Diagnosis Description Primary Rx

5366287766 Active_Child_9_M 21,141$ 437,457$ 458,598$ E84.0 Cystic fibrosis with pulmonary manifestations TRIKAFTA 7106686678 RetU65_Subscriber_45_M 299,005$ 202$ 299,207$ N18.6 end-stage renal disease GENTAMICIN 6906197302 Active_Subscriber_47_M 11,119$ 278,347$ 289,466$ Z00.00; G47.33 Obstructive Sleep Apnea ILARIS, TOUJEO MAX 3946161840 Active_Spouse_35_F 276,614$ 9,400$ 286,015$ G40.909 Epilepsy, unspecified, not intractable, without status epilepticus BOTOX

2036570659 Active_Subscriber_55_F 269,587$ 7,136$ 276,723$ C83.39 Diffuse large B-cell lymphoma, extranodal and solid organ sites JARDIANCE 5296176843 Active_Child_<1_F 264,895$ 407$ 265,302$ P05.14, P22.0 Newborn small for gestational age, unspecified weight, Respiratory distress syndrome of newborn

FAMOTIDINE

6506090641 Active_Subscriber_69_M 228,119$ 11,121$ 239,239$ C18.3 Malignant neoplasm of hepatic flexure APREPITANT 2336573600 Active_Subscriber_29_M 49$ 219,375$ 219,424$ M62.830; Q61.2 Muscle spasm of back; Polycystic kidney, adult type JYNARQUE 5576161182 Active_Spouse_47_F 167,617$ 50,482$ 218,100$ C90.01 Multiple myeloma in remission POMALYST 5816142229 Active_Subscriber_69_M 5,776$ 185,177$ 190,953$ D50.0 Iron deficiency anemia secondary to blood loss (chronic) JAKAFI 3416142971 Active_Subscriber_58_M 188,972$ 28$ 189,001$ C7A.00 Malignant carcinoid tumor of unspecified site AMLOD/VALSAR 5616422509 RetU65_Subscriber_64_M 3,797$ 161,879$ 165,675$ C61 Malignant neoplasm of prostate XTANDI 8146605197 RetU65_Spouse_61_F 103,166$ 59,985$ 163,151$ M16.12 Unilateral primary osteoarthritis in the left hip HUMIRA PEN 0096005888 Active_Spouse_34_F 137,322$ 23,697$ 161,018$ C50.812 Malignant neoplasm of overlapping sites of the left female breast VERZENIO

5286820502 RetU65_Subscriber_63_M 142,837$ 15,645$ 158,482$ C7A.1 Malignant poorly differentiated neuroendocrine tumors FARXIGA, XARELTO 4036995746 Active_Subscriber_25_F 154,456$ 1,546$ 156,002$ I47.10 Unspecified supraventricular tachycardia EPINEPHRINE

2,274,472$ 1,461,884$ 3,736,356$

Maxor+ (Pharmacy), Eff 1/1/26: RxBenefits(Optum-Pharmacy) Page 4 of 4