BI_Monthly_CITY_OF_EDINBURG_000243483_ALL_202504.pdf

Blue Insight℠ Monthly Financial Report

10/01/2024 to 04/30/2025

CITY OF EDINBURG 000243483: ALL

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association © Copyright 2025 Health Care Service Corporation. All rights reserved.

Data Parameters 3

Enrollment Overview 4-5

Financial Overview

Financial Summary 6

Medical & Pharmacy Loss Ratio 7

Network Overview 8

Blue Card Savings Analysis 9

Medical Claim Expense Distribution 10

High Cost Claimants 11

Medical Out of Pocket 12

Lag Report 13

Overall Medical Paid PMPM Leading Diagnostic Category 14

PLAN PERFORMANCE

Pharmacy

Financial Summary 15

Key Indicators 16

Generic vs. Formulary Experience 17

Top Non-Specialty Drug Classes and Drugs 18

Specialty Drug Analysis 19

Dental

Dental Financial Summary 20

Dental Loss Ratio 21

Appendix 22

Glossary 25

CITY OF EDINBURG 000243483: ALL

Table of Contents

Current Period: The current reporting period represents claims paid from October 1, 2024 through April 30, 2025.

Prior Period: The prior reporting period represents claims paid from October 1, 2023 through April 30, 2024.

Reporting Support Contact Information

For reporting support, please contact Client Reporting Service Center Email: client_reporting@bcbsil.com Hours of Operation: Monday - Friday: 8:00am - 5:00pm CT

Report prepared on 05/14/2025

The report includes medical claims, pharmacy claims and dental claims.

Reporting Segments: ALL

Characteristics: ALL

Group/Sections: ALL

CITY OF EDINBURG 000243483: ALL

Data Parameters

Report Description: Provides the current enrollment based on the current period.

Month Medical

Subscribers Medical Members

Pharmacy Subscribers

Pharmacy Members

Dental Subscribers

Dental Members

Oct 2024 1,103 1,738 1,103 1,738 1,076 1,820 Nov 2024 1,091 1,717 1,091 1,717 1,069 1,801 Dec 2024 1,101 1,725 1,101 1,725 1,077 1,808 Jan 2025 1,098 1,717 1,098 1,717 1,077 1,808 Feb 2025 1,089 1,709 1,089 1,709 1,066 1,797 Mar 2025 1,096 1,718 1,096 1,718 1,072 1,798 Apr 2025 1,092 1,709 1,092 1,709 1,067 1,783 May 2025 Jun 2025 Jul 2025 Aug 2025 Sep 2025

CITY OF EDINBURG 000243483: ALL

Enrollment Overview

• Overall, membership decreased by 2.1% between reporting periods.

• The average age was 33.1 and remained stable by 0.0% between reporting periods.

• Contract size remained stable by 0.0% between reporting periods.

• Females between the ages of 20 and 44 decreased from 17.0% to 16.9% between reporting periods.

Report Description: Provides medical demographics for the current period compared to the prior period and percent change.

Medical Demographics Oct 2023 - Apr 2024 Oct 2024 - Apr 2025 % Change

Average Membership 1,755 1,719 -2.1%

Employee 1,102 1,096 -0.5%

Spouse 118 111 -5.9%

Dependent 535 512 -4.3%

Average Contract Size 1.6 1.6

Average Age 33.1 33.1

Employee 41.5 41.3 -0.5%

Spouse 44.2 43.3 -2.0%

Dependent 13.6 13.4 -1.5%

% Under 30 45.1% 45.0%

% 30 to 49 33.9% 34.3%

% 50 to 64 19.6% 19.4%

% 65+ 1.3% 1.3%

Gender

Proportion of Males 62.6% 61.9%

Proportion of Females 37.4% 38.1%

Females Ages 20-44 17.0% 16.9%

CITY OF EDINBURG 000243483: ALL

Enrollment Overview

Medical Order of Reduction

Paid Month Apr 2025 Oct 2023 - Apr 2024 Oct 2024 - Apr 2025 % Change Billed $2,771,756 $20,161,628 $17,152,809 -14.9% Not Covered $140,614 $3,481,903 $1,672,865 -52.0% Covered $2,631,141 $16,679,725 $15,479,944 -7.2% Discount $1,847,308 $12,266,782 $11,228,303 -8.5% Allowed $783,834 $4,412,943 $4,251,641 -3.7% Out of Pocket $129,774 $851,397 $840,927 -1.2%

COB $702 $12,902 $14,951 15.9%

COB Medicare $159,335 $416,042 $160,546 -61.4% Other Reductions ($23,965) $2,370 $84 -96.5% Other Adjustments ($100) ($485) ($1,217) -151.0% Paid - Provider $518,089 $3,130,716 $3,236,349 3.4% Other Payments $161 $4,574 $30 -99.4% Medical Paid $518,250 $3,135,290 $3,236,379 3.2%

Report Description: Provides a breakdown of the medical order of reduction from billed to paid for the current month, current period, prior period and a percent change. This report may highlight key measures and their potential impact on paid expenses.

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

Other payments includes Blue Card access fees and surcharges. Also displayed are other adjustments.

Group Liability Breakdown Paid Month Apr 2025 Oct 2023 - Apr 2024 Oct 2024 - Apr 2025 % Change

Medical Paid $518,250 $3,135,290 $3,236,379 3.2% Pharmacy Paid $174,483 $1,154,159 $1,384,730 20.0% Dental Paid $29,500 $149,497 $166,405 11.3% VBC Payments $250 $2,049 $1,020 -50.3% Total Paid Claims $722,482 $4,440,995 $4,788,534 7.8% Recoveries $0 $0 $0 0.0% Total Paid Claims + Recoveries $722,482 $4,440,995 $4,788,534 7.8%

HCA Draft Amount $0 $0 $0 0.0% Capitation Paid $0 $0 $0 0.0% Group Liability $722,482 $4,440,995 $4,788,534 7.8%

CITY OF EDINBURG 000243483: ALL

Financial Overview: Financial Summary

Report Description: Provides the medical and pharmacy loss ratio and claims for the most recent reported twelve months.

Month Premium Medical Paid Claims Pharmacy Paid Claims Capitation VBC Payments Total Paid Medical and Pharmacy Loss Ratio May 2024 $809,231 $632,889 $248,475 $0 $313 $881,677 109.0% Jun 2024 $803,815 $370,284 $151,745 $0 $294 $522,323 65.0% Jul 2024 $798,860 $420,750 $208,148 $0 $256 $629,154 78.8% Aug 2024 $801,329 $648,111 $252,963 $0 $12 $901,085 112.5% Sep 2024 $801,739 $406,452 $183,115 $0 $9 $589,577 73.5% Oct 2024 $808,327 $374,021 $179,023 $0 $6 $553,050 68.4% Nov 2024 $802,102 $441,818 $226,509 $0 $4 $668,331 83.3% Dec 2024 $805,199 $499,700 $188,638 $0 $258 $688,597 85.5% Jan 2025 $800,881 $538,424 $172,924 $0 $253 $711,601 88.9% Feb 2025 $799,544 $490,068 $233,475 $0 $5 $723,548 90.5% Mar 2025 $802,685 $374,099 $209,677 $0 $244 $584,020 72.8% Apr 2025 $800,226 $518,250 $174,483 $0 $250 $692,982 86.6% Summary $9,633,940 $5,714,865 $2,429,177 $0 $1,903 $8,145,945 84.6%

Key Findings: The medical and pharmacy loss ratio for the most recent reported month was 2.0% higher than the average of the most recent reported twelve months, which was 84.6%.

CITY OF EDINBURG 000243483: ALL

Financial Overview: Medical & Pharmacy Loss Ratio

Report Description: This report displays the discount amount, discount percent, paid amount and paid percent for medical claims split by Medicare/Non-Medicare, in/out of network and service category for the current period.

Key Findings: The overall network savings discount (excluding Medicare) was 73.4% for the current period. The in-network paid percent was 99.8% for the current period.

Medicare Primary Indicator Network Indicator Service Category Covered Discount Discount % Paid % Of Paid

No

In Network

Facility Inpatient $2,821,027 $1,963,594 69.6% $788,329 24.4%

Facility Outpatient $8,560,296 $6,844,658 80.0% $1,286,540 39.8%

Professional $3,884,485 $2,393,652 61.6% $1,155,328 35.7%

Summary $15,265,808 $11,201,904 73.4% $3,230,196 99.8%

Out of Network

Facility Inpatient

Facility Outpatient $3,713 $2,239 60.3%

Professional $41,036 $22,754 55.4% $5,248 0.2%

Summary $44,749 $24,993 55.9% $5,248 0.2%

Summary $15,310,557 $11,226,897 73.3% $3,235,444 100.0%

Yes

In Network

Facility Inpatient $165,310 $375

Facility Outpatient

Professional $4,077 $1,406 34.5% $560

Summary $169,387 $1,406 0.8% $935

Out of Network

Facility Inpatient

Facility Outpatient

Professional

Summary

Summary $169,387 $1,406 0.8% $935

Summary $15,479,944 $11,228,303 72.5% $3,236,379 100.0%

CITY OF EDINBURG 000243483: ALL

Financial Overview: Network Overview

Report Description: The Blue Card Savings report illustrates the value of having access to other BCBS contracts within the United States through the Blue Card program. Savings from BCBS network discounts are passed to the client, providing savings on potentially costly out of state claims that would otherwise be paid at full provider billed amount.

Oct 2024 - Apr 2025

Par Plan State Billed Allowed Effective Allowed Rate Discount Paid Effective

Paid Rate Blue Card Access Fee

OH $33,251 $20,659 62.1% $10,036 $17,199 51.7% $337

NJ $7,300 $682 9.3% $6,618 $911 12.5% $229

IL $42,912 $45,512 106.1% $6,284 $44,498 103.7% $0

LA $476 ($3,749) -788.2% $3,999 ($3,781) -795.0% $2

UT $1,745 $1,000 57.3% $745 $1,026 58.8% $26

ND $905 $610 67.4% $295 $480 53.0% $10

CT $297 $40 13.5% $257 $49 16.5% $9

FL $459 $205 44.6% $254 $213 46.4% $8

MI $655 $431 65.8% $224 $182 27.8% $8

AR $255 $174 68.2% $81 $177 69.3% $3

All Other Blue Card $3,142 $990 31.5% ($990) $772 24.6% $52

All Other Non-Blue Card $17,061,412 $4,185,087 24.5% $11,200,499 $3,174,655 18.6% $0

Summary $17,152,809 $4,251,641 24.8% $11,228,303 $3,236,379 18.9% $683

Key Findings: OH had the greatest Blue Card savings amount, with a Discount amount of $10,036. The overall Effective Allowed Rate for the current period was 24.8%.

CITY OF EDINBURG 000243483: ALL

Financial Overview: Blue Card Savings Analysis

Report Description: The distribution of medical paid expense by claimant and the average medical paid per claimant amount are shown for the current period.

Paid Band Claimants Claimants % Paid Paid % Paid/Claimant

Less than $200 412 29.9% $5,067 0.2% $12

$200 - $1,000 535 38.8% $263,991 8.2% $493

$1,001 - $5,000 339 24.6% $776,086 24.0% $2,289

$5,001 - $10,000 41 3.0% $288,874 8.9% $7,046

$10,001 - $30,000 36 2.6% $567,898 17.5% $15,775

$30,001 - $50,000 7 0.5% $269,256 8.3% $38,465

Summary <= $50,000 1,370 99.3% $2,171,172 67.1% $1,585

Paid Band Claimants Claimants % Paid Paid % Paid/Claimant

$50,001 - $75,000 4 0.3% $253,170 7.8% $63,292

$75,001 - $100,000 1 0.1% $83,079 2.6% $83,079

$100,001 - $150,000 2 0.1% $252,931 7.8% $126,465

$150,001 - $200,000 1 0.1% $169,746 5.2% $169,746

$200,001 - $250,000

$250,001 - $500,000 1 0.1% $306,282 9.5% $306,282

$500,001+

Summary $50,001 or Greater 9 0.7% $1,065,207 32.9% $118,356

Combined Summary 1,379 100.0% $3,236,379 100.0% $2,347

Key Findings: The proportion of claimants who received less than $200 in services for the current period was 29.9%. These claimants spent 0.2% of the total paid expenses and the average paid expense per claimant was $12. 0.7% of claimants had expenses over $50,001 for the current period. These claimants spent 32.9% of the total paid expenses and the average paid expense per claimant was $118,356.

CITY OF EDINBURG 000243483: ALL

Financial Overview: Medical Claim Expense Distribution

Report Description: This report provides a detailed listing of the top 20 high cost claimants with paid expenses of $50,000 or more for the current period.

Oct 2024 - Apr 2025

Encrypted Member ID Relationship Age/Gender Band Leading Diagnostic Category

Inpatient Paid

Outpatient Paid

Professional Paid

Pharmacy Paid Paid

Currently Enrolled

646574445239229123 Subscriber Male 40-49 Neoplasms $277,739 $4,790 $23,753 $10,206 $316,488 Yes

2798112031089723080 Dependent Male <1-19 Perinatal $167,755 $0 $1,991 $0 $169,746 No

7782240017087466827 Spouse Male 40-49 Neoplasms $4,542 $131,459 $6,581 $1,352 $143,934 Yes

4190546441697925354 Subscriber Female 50-59 Not Available $0 $11,740 $1,403 $109,385 $122,528 Yes

3726969073906687299 Dependent Female <1-19 Injury/Poisoning $101,341 $5,797 $3,211 $0 $110,349 Yes

4433474454332789707 Subscriber Male 40-49 Nervous $0 $586 $82,493 $105 $83,184 Yes

386634004531145816 Subscriber Male 50-59 Genitourinary $33,432 $23,003 $13,884 $9,542 $79,861 Yes

4166761678164003741 Subscriber Male 40-49 Neoplasms $13,626 $37,903 $12,733 $10,981 $75,243 Yes

6857144571589587445 Subscriber Female 50-59 Not Available $0 $0 $1,634 $71,168 $72,802 Yes

1075467586486695097 Subscriber Female 40-49 Infectious/Parasitic $24,121 $7,565 $35,280 $3,902 $70,868 Yes

2085204052264203850 Subscriber Female 40-49 Not Available $0 $0 $800 $50,919 $51,719 Yes

8871942475241677439 Dependent Male <1-19 Congenital $0 $49,257 $2,365 $13 $51,635 Yes

High Cost Claimant Total $622,556 $272,100 $186,128 $267,573 $1,348,357

CITY OF EDINBURG 000243483: ALL

Financial Overview: High Cost Claimants

Oct 2023 - Apr 2024 Oct 2024 - Apr 2025 % Change Out of Pocket Band Claimants Claimants % Out of Pocket Out of Pocket % Claimants Claimants % Out of Pocket Out of Pocket % Claimants Change Out of Pocket Change

Less than $100 584 42.3% $23,057 2.7% 598 43.4% $19,100 2.3% 2.4% -17.2%

$101 - $200 255 18.5% $35,948 4.2% 237 17.2% $33,169 3.9% -7.1% -7.7%

$201 - $300 121 8.8% $29,327 3.4% 120 8.7% $29,489 3.5% -0.8% 0.6%

$301 - $400 51 3.7% $18,335 2.2% 54 3.9% $19,098 2.3% 5.9% 4.2%

$401 - $500 31 2.2% $14,042 1.6% 34 2.5% $15,419 1.8% 9.7% 9.8%

$501 - $750 65 4.7% $40,071 4.7% 62 4.5% $38,224 4.5% -4.6% -4.6%

$751 - $1,000 43 3.1% $38,138 4.5% 34 2.5% $29,891 3.6% -20.9% -21.6%

$1,001 - $1,500 70 5.1% $86,715 10.2% 60 4.4% $74,068 8.8% -14.3% -14.6%

$1,501 - $2,000 42 3.0% $72,027 8.5% 53 3.8% $92,196 11.0% 26.2% 28.0%

$2,001 - $2,500 24 1.7% $54,146 6.4% 28 2.0% $61,784 7.3% 16.7% 14.1%

$2,501 - $3,000 20 1.4% $55,811 6.6% 23 1.7% $63,823 7.6% 15.0% 14.4%

$3,001 - $4,000 30 2.2% $102,460 12.0% 34 2.5% $115,055 13.7% 13.3% 12.3%

$4,001 - $5,000 12 0.9% $54,191 6.4% 14 1.0% $61,487 7.3% 16.7% 13.5%

$Greater than $5,001 34 2.5% $227,128 26.7% 28 2.0% $188,124 22.4% -17.6% -17.2%

Summary 1,382 100% $851,397 100% 1,379 100% $840,927 100% -0.2% -1.2%

Report Description: Provides a distribution of claimants by their total medical out of pocket expenses for the current period compared to the prior period and percent change.

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

Coverage Tier Allowed Deductible Deductible % of Allowed Copayment Copay % of Allowed Coinsurance Coins % of Allowed Out of Pocket OPX % of Allowed Paid

Employee Only $1,593,031 $158,224 9.9% $102,741 6.4% $100,744 6.3% $361,709 22.7% $1,069,080 Employee + One $309,086 $25,230 8.2% $17,788 5.8% $25,075 8.1% $68,092 22.0% $237,755 Employee + Dependent(s) $1,448,474 $86,947 6.0% $81,091 5.6% $102,271 7.1% $270,308 18.7% $1,172,309 Family $901,051 $51,561 5.7% $40,459 4.5% $48,798 5.4% $140,818 15.6% $757,236 Summary $4,251,641 $321,961 7.6% $242,078 5.7% $276,889 6.5% $840,927 19.8% $3,236,379

This is a claimant analysis, where only members who had a claim are included. The tables exclude all medical enrolled members that did not submit a claim.

This report is based on claim data and may not reflect client specific benefits being applied to member out of pocket. Please contact your Account Executive for ACCUMS reporting.

Claimant Distribution by Out of Pocket Expense Bands

Out of Pocket Expense by Coverage Tier Oct 2024 - Apr 2025

CITY OF EDINBURG 000243483: ALL

Financial Overview: Medical Out of Pocket

Incurred Month

Paid Month May 2024 Jun 2024 Jul 2024 Aug 2024 Sep 2024 Oct 2024 Nov 2024 Dec 2024 Jan 2025 Feb 2025 Mar 2025 Apr 2025 Summary

All Prior $1,202 $7,766 ($2,110) $4,650 $6,073 $118 $10,806 $2,397 $3,510 $376 $121 $34,909

May 2023 $283 $25 $51 $34 $447 $5,041 $139 $6,020

Jun 2023 $566 ($300) $133 $786 $1,186

Jul 2023 $38 ($1,363) $1,833 $66 ($251) $16 $19 $359

Aug 2023 $67 $314 $468 $19 $58 $38 $964

Sep 2023 $11 $24 $144 $119 $24 $321

Oct 2023 $74 $718 $380 $55 $106 $413 $89 $1,834

Nov 2023 $750 $1,615 $4,579 $564 $62 ($419) $40 $62 $24 $7,277

Dec 2023 $664 $1,319 $412 ($109) $3,304 $78 $19 $5,688

Jan 2024 $2,653 $2,222 $1,056 ($5,097) $801 $242 ($6,101) $99 $194 ($3,930)

Feb 2024 $11,496 $8,232 $777 ($25) ($3,941) ($13,401) ($6,687) $414 $49 $44 ($3,041)

Mar 2024 $288,082 $6,866 $1,024 $979 $469 $576 $302 $124 $1,643 ($495) $25 $299,596

Apr 2024 $148,660 $36,821 $11,040 $786 $1,279 $923 $619 $56 ($538) $959 ($4,250) $196,355

May 2024 $178,907 $141,129 $42,286 $6,070 $262 $294 ($374) $277 $164 $47 ($964) $368,099

Jun 2024 $164,055 $112,155 $51,433 $3,654 $455 $3 $391 $66 ($221) $76 $205 $332,271

Jul 2024 $247,319 $194,787 $10,630 $2,392 $516 ($67) $240 ($1,077) ($12,307) ($23) $442,410

Aug 2024 $393,405 $145,498 $12,343 $1,796 $5,609 $142 ($11) $1,130 $559,913

Sep 2024 $241,966 $105,433 $7,285 $7,618 $646 $358 $1,237 $712 $365,255

Oct 2024 $264,449 $147,687 $182,155 $9,207 $2,193 $591 $1,391 $607,671

Nov 2024 $276,812 $38,132 $185,208 $2,030 $5,042 $1,104 $508,328

Dec 2024 $268,660 $130,706 $7,471 $2,218 $225 $409,280

Jan 2025 $208,181 $112,354 $15,862 $6,742 $343,139

Feb 2025 $358,816 $111,017 $21,120 $490,953

Mar 2025 $253,506 $142,873 $396,380

Apr 2025 $343,630 $343,630

Summary $632,889 $370,284 $420,750 $648,111 $406,452 $374,021 $441,818 $499,700 $538,424 $490,068 $374,099 $518,250 $5,714,865

Report Description: Displays, by paid month, the medical dollars paid and the corresponding month incurred for a 12 month rolling paid period (if available for your account).

This report provides insight into the monthly claim lag and can help identify IBNR.

CITY OF EDINBURG 000243483: ALL

Financial Overview: Lag Report

Report Description: Lists the top 15 overall paid expense across inpatient facility, outpatient facility, and professional settings by leading diagnostic categories for the current month, current period, prior period and percent change.

Paid Period Apr 2025 Oct 2023 - Apr 2024

Oct 2024 - Apr 2025 % Change

Leading Diagnostic Category Paid PMPM Paid PMPM Paid PMPM Paid PMPM

Neoplasms $65 $49 $45 -8.2%

Health Status $34 $26 $34 30.8%

Infectious/Parasitic $33 $9 $12 33.3%

Nervous $27 $11 $12 9.1%

Genitourinary $23 $15 $22 46.7%

Musculoskeletal $11 $8 $11 37.5%

Endocrine $16 $10 $15 50.0%

Symptoms/Ill-Defined $16 $16 $14 -12.5%

Mental Health $11 $10 $11 10.0%

Pregnancy $10 $10 $6 -40.0%

Digestive $9 $22 $11 -50.0%

Injury/Poisoning $8 $9 $21 133.3%

Blood $8 $3 $4 33.3%

External Causes $8 $1 0.0%

Respiratory $7 $16 $8 -50.0%

All Other Values $18 $41 $43 4.9%

Summary $303 $255 $269 5.5%

Key Findings: The top three Leading Diagnostic Categories in the current reporting month based on Paid PMPM were Neoplasms, Health Status, and Infectious/Parasitic.

CITY OF EDINBURG 000243483: ALL

Financial Overview: Overall Medical Paid PMPM by Leading Diagnostic Category

Report Description:

This report provides an overview of the pharmacy order of reduction from billed to paid for the current month, current period, prior period, and percent change.

Pharmacy Order of Reduction Apr 2025 Oct 2023 - Apr 2024 Oct 2024 - Apr 2025 % Change

Billed $355,600 $2,406,450 $2,790,135 15.9% Discount $167,637 $1,161,339 $1,309,441 12.8% Allowed $187,963 $1,245,111 $1,480,695 18.9% Out of Pocket $13,465 $95,432 $98,841 3.6% Other Adjustments $15 ($4,480) ($2,877) 35.8% Paid - Provider $174,483 $1,154,159 $1,384,730 20.0% Paid $174,483 $1,154,159 $1,384,730 20.0%

Total Paid Specialty Paid Non Specialty Paid

Prior $1,154,159 $270,807 $883,352

Current $1,384,730 $471,474 $913,256

CITY OF EDINBURG 000243483: ALL

Pharmacy: Financial Summary

Report Description: This report provides an overview of the prescription expenses for the current month. Prescription expenses and percent changes between the current and prior reporting periods are provided as well.

Key Indicators Summary Key Indicators Summary Apr 2025 Oct 2023 - Apr 2024 Oct 2024 - Apr 2025 % Change Unique Pharmacy Members 1,709 1,903 1,885 -0.9% Claimants 480 1,192 1,171 -1.8% Prescriptions 1,451 11,155 11,562 3.6% Prescriptions PMPM 0.85 0.91 0.96 5.8% Paid $174,483 $1,154,159 $1,384,730 20.0% Paid PMPM $102.10 $93.95 $115.08 22.5% Allowed $187,963 $1,245,111 $1,480,695 18.9% Allowed PMPM $109.98 $101.35 $123.05 21.4% Avg. Ingredient Cost/Prescription $129.44 $111.49 $127.96 14.8% Generic Dispensing Rate 84.4% 86.1% 85.2% -1.0% Generic Substitution Rate 98.1% 99.0% 98.2% -0.8% Out of Pocket Percent of Allowed 7.2% 7.7% 6.7% -12.9% Retail as a Percent of Prescriptions 99.7% 99.7% 99.8% 0.1% Mail Order as a Percent of Prescriptions 0.3% 0.3% 0.2% -34.5% Specialty Percent of Total Prescriptions 2.1% 1.8% 2.0% 6.9% Specialty Percent of Total Paid 35.3% 23.5% 34.0% 45.1% Specialty Average Ingredient Cost/Prescription $2,003.18 $1,326.71 $2,098.16 58.1%

Cost Sharing Distribution

Cost Sharing Distribution Apr 2025 Oct 2023 - Apr 2024 Oct 2024 - Apr 2025 % Change

Retail Mail Retail Mail Retail Mail Retail Mail Member Out of Pocket 7.2% 100.0% 7.6% 100.0% 6.7% 100.0% -12.7% 0.0% Plan Paid 92.9% 0.0% 92.4% 0.0% 93.4% 0.0% 1.1% 0.0%

CITY OF EDINBURG 000243483: ALL

Pharmacy: Key Indicators

Report Description: For the current period, the prescription drug expenses are displayed below for retail and mail order providers and broken out by drug type and formulary indicator.

Total Expense Member Expense Plan Expense

Total Prescriptions Prescriptions % of Total

Prescriptions Allowed Allowed /

Prescription Out of Pocket Out of Pocket /

Prescription Paid Paid/

Prescription Generic 9,839 85% $105,695 $10.74 $49,189 $5.00 $56,559 $5.75 Brand 1,723 15% $1,375,000 $798.03 $49,653 $28.82 $1,328,171 $770.85 Summary 11,562 100% $1,480,695 $128.07 $98,841 $8.55 $1,384,730 $119.77

Brand Type Breakdown Single-Source Brand 1,454 13% $1,180,652 $812.00 $41,443 $28.50 $1,142,737 $785.93 Multi-Source Brand 269 2% $194,348 $722.48 $8,210 $30.52 $185,434 $689.35 Multi-Source Brand w/ DAW1 42 0% $4,204 $100.09 $1,444 $34.39 $2,589 $61.64 Multi-Source Brand w/ DAW2 133 1% $48,682 $366.03 $3,882 $29.19 $44,302 $333.10

Brand Formulary 1,715 15% $1,372,789 $800.46 $49,258 $28.72 $1,326,355 $773.38 Brand Non-Formulary 8 0% $2,211 $276.39 $395 $49.38 $1,816 $227.02

Total Expense Member Expense Plan Expense

Mail Prescriptions Prescriptions % of Total

Prescriptions Allowed Allowed /

Prescription Out of Pocket Out of Pocket /

Prescription Paid Paid/

Prescription Generic 21 100% $131 $6.22 $131 $6.22 $0 $0.00 Brand Summary 21 100% $131 $6.22 $131 $6.22 $0 $0.00

Single-Source Brand Multi-Source Brand Multi-Source Brand w/ DAW1 Multi-Source Brand w/ DAW2

Brand Formulary Brand Non-Formulary

Total Expense Member Expense Plan Expense

Retail Prescriptions Prescriptions % of Total

Prescriptions Allowed Allowed /

Prescription Out of Pocket Out of Pocket /

Prescription Paid Paid/

Prescription Generic 9,818 85% $105,564 $10.75 $49,058 $5.00 $56,559 $5.76 Brand 1,723 15% $1,375,000 $798.03 $49,653 $28.82 $1,328,171 $770.85 Summary 11,541 100% $1,480,564 $128.29 $98,711 $8.55 $1,384,730 $119.98

Brand Type Breakdown Single-Source Brand 1,454 13% $1,180,652 $812.00 $41,443 $28.50 $1,142,737 $785.93 Multi-Source Brand 269 2% $194,348 $722.48 $8,210 $30.52 $185,434 $689.35 Multi-Source Brand w/ DAW1 42 0% $4,204 $100.09 $1,444 $34.39 $2,589 $61.64 Multi-Source Brand w/ DAW2 133 1% $48,682 $366.03 $3,882 $29.19 $44,302 $333.10

Brand Formulary 1,715 15% $1,372,789 $800.46 $49,258 $28.72 $1,326,355 $773.38 Brand Non-Formulary 8 0% $2,211 $276.39 $395 $49.38 $1,816 $227.02

CITY OF EDINBURG 000243483: ALL

Pharmacy: Generic vs. Formulary Experience

Report Description: The top 10 therapeutic and prescription drug classes and drugs for the current period are displayed below ranked by ingredient cost.

Current/ Prior Rank Plan Therapeutic Class Prescriptions

Utilizing Members Ingredient Cost

Avg. Ingredient Cost/

Prescription (Current)

Avg. Ingredient Cost/

Prescription (Prior)

Generic

Rank by Volume

1 1 Incretin Mimetic Agents 521 103 $472,475 $906.86 $892.79 2 2 2 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 210 46 $103,432 $492.53 $531.37 16 3 3 Antidiabetic Combinations 220 43 $91,061 $413.92 $437.55 9.6% 15 4 Calcitonin Gene-Related Peptide (CGRP) Receptor Antag 20 5 $29,145 $1,457.24 $1,217.00 91 5 5 Insulin 95 22 $27,407 $288.49 $327.34 36 6 6 Sympathomimetics 164 101 $21,354 $130.21 $116.12 62.8% 22 7 4 Antiviral Combinations 14 16 $19,176 $1,369.73 $908.35 100 8 Cardiovascular Agents Misc. - Combinations 24 4 $13,836 $576.49 $579.84 86 9 10 Direct Factor Xa Inhibitors 25 5 $13,268 $530.72 $491.96 83

10 7 Viral Vaccines 143 110 $12,472 $87.22 $92.53 24 All Other 9,900 1,137 $201,690 $20.37 $17.96 96.6% Summary 11,336 1,165 $1,005,316 $88.68 $88.85 85.4%

Current/ Prior Rank Brand Name Plan Therapeutic Class Prescriptions

Utilizing Members

Ingredient Cost

Avg. Ingredient Cost/

Prescription (Current)

Avg. Ingredient Cost/

Prescription (Prior)

Generic Indicator

Rank by Volume

1 2 OZEMPIC INJ 8MG/3ML Incretin Mimetic Agents 86 17 $77,165 $897.27 $891.67 NO 7 2 3 OZEMPIC INJ 4MG/3ML Incretin Mimetic Agents 91 19 $76,734 $843.23 $894.27 NO 5 3 16 MOUNJARO INJ 7.5/0.5 Incretin Mimetic Agents 71 22 $70,371 $991.14 $964.48 NO 10 4 1 OZEMPIC INJ 2MG/3ML Incretin Mimetic Agents 63 22 $45,152 $716.69 $786.41 NO 14 5 10 FARXIGA TAB 10MG Sodium-Glucose Co-Transporter 2 (SGLT2 84 15 $44,306 $527.46 $523.23 NO 8 6 11 MOUNJARO INJ 15MG/0.5 Incretin Mimetic Agents 44 7 $42,819 $973.16 $990.43 NO 25 7 5 MOUNJARO INJ 5MG/0.5 Incretin Mimetic Agents 42 15 $41,928 $998.29 $1,012.02 NO 27 8 7 JARDIANCE TAB 25MG Sodium-Glucose Co-Transporter 2 (SGLT2 59 17 $30,076 $509.77 $519.33 NO 17 9 17 RYBELSUS TAB 14MG Incretin Mimetic Agents 30 5 $27,168 $905.60 $876.06 NO 59

10 8 MOUNJARO INJ 10MG/0.5 Incretin Mimetic Agents 26 12 $26,536 $1,020.62 $944.53 NO 82 All Other 10,740 1,162 $523,061 $48.70 $52.65 Summary 11,336 1,165 $1,005,316 $88.68 $88.85

CITY OF EDINBURG 000243483: ALL

Pharmacy: Top Non-Specialty Drug Classes and Drugs

Report Description: Specialty drugs generally have unique uses, require special dosing or administration, are typically prescribed by a specialist provider and are significantly more expensive than alternative drugs or therapies. This report provides specialty drug analysis for the current month, current period, prior period and percent change.

Top 10 Specialty Drugs by Ingredient Cost for the Current Period

Brand Name Specialty Class Ingredient

Cost Prescriptions

Avg. Ingredient Cost/

Prescription Specialty Claimants

REVLIMID CAP 10MG CANCER $109,352 6 $18,225.28 1

ENBREL SRCLK INJ 50MG/ML AUTOIMMUNE $98,349 13 $7,565.29 2

COSENTYX UNO INJ 300/2ML AUTOIMMUNE $50,987 7 $7,283.86 1

GENOTROPIN INJ 12MG GROWTH HORMONES $46,828 5 $9,365.67 1

SKYRIZI PEN INJ 150MG/ML AUTOIMMUNE $41,615 6 $6,935.89 1

STELARA INJ 45MG/0.5 AUTOIMMUNE $40,091 7 $5,727.35 1

DUPIXENT INJ 300/2ML AUTOIMMUNE $30,167 8 $3,770.89 1

HUMIRA PEN INJ 40/0.4ML AUTOIMMUNE $19,725 3 $6,575.10 1

ACTEMRA INJ ACTPEN AUTOIMMUNE $16,480 7 $2,354.32 1

OTEZLA TAB 30MG AUTOIMMUNE $10,158 2 $5,078.81 1

All Other $10,430 162 $64.38 134 Summary $474,183 226 $2,098.16 144

Specialty Drug Key Indicators Apr 2025 Oct 2023 - Apr 2024 Oct 2024 - Apr 2025 % Change

Unique Pharmacy Members 1,709 1,903 1,885 -1.0%

Claimants 29 126 144 14.3%

Percent of Utilizing Members 1.7% 6.6% 7.6% 15.4%

Prescriptions 31 204 226 10.8%

Specialty Percent of Total Paid 35.3% 23.5% 34.1% 45.1%

Percent of Total Prescriptions Paid 2.1% 1.8% 2.0% 6.9%

Paid $61,628 $270,807 $471,474 74.1%

Paid PMPM $36.06 $22.04 $39.18 77.8%

Average Ingredient Cost/Prescription $2,003 $1,327 $2,098 58.2%

Prior period is reflected only as it pertains to the Top 5 Speciality Classes of current period.

CITY OF EDINBURG 000243483: ALL

Pharmacy: Specialty Drug Analysis

• DIAGNOSTIC procedures accounted for 37% of total dollars for the current reporting period.

• Male PMPM is $5.86 less than Female PMPM for the current reporting period.

Financial Overview: Oct 2024 - Apr 2025

Service Category Claimants Claims Average Cost per Claim

Previous Average Cost per Claim % Change PMPM Benchmark % Variance from

Benchmark

ADJUNCTIVE

GENERAL SERVICES 40 53 $17.81 $34.57 -48% $0.07 $0.26 -71%

ALL OTHER

SERVICES 1 1 $0.00 $0.00 0% $0.00 $0.00 -100%

DIAGNOSTIC 560 707 $87.46 $93.32 -6% $4.90 $7.72 -37%

ENDODONTICS 21 21 $252.53 $375.85 -33% $0.42 $1.14 -63%

IMPLANT SERVICES 6 12 $80.54 $173.08 -53% $0.08 $0.48 -84%

ORAL SURGERY 53 68 $116.75 $154.33 -24% $0.63 $1.46 -57%

ORTHODONTICS 14 53 $109.38 $144.26 -24% $0.46 $1.52 -70%

Other - Dental 3 3 $219.70 $412.00 -47% $0.05 $0.02 157%

PERIODONTICS 64 97 $77.20 $74.09 4% $0.59 $1.26 -53%

PREVENTIVE 477 537 $61.76 $58.85 5% $2.63 $5.00 -47%

PROSTHODONTICS,

FIXED 3 3 $201.33 $358.65 -44% $0.05 $0.20 -76%

PROSTHODONTICS,

REMOVABLE 6 7 $52.61 $0.00 0% $0.03 $0.23 -87%

RESTORATIVE 152 203 $203.62 $201.15 1% $3.28 $6.09 -46%

Totals 1096 $151.83 $166.85 $25.35

Top 10 Procedure Service Type

Description Counts Prior Reporting period count PMPM by Service Type Service Type PMPM

Benchmark Clinical Oral Evaluation 686 574 $1.92 $3.53

Radiographs/Diagnostic Imaging 615 521 $2.98 $4.17 Dental Prophylaxis 522 460 $2.15 $4.21

Topical Fluoride Treatment 237 187 $0.26 $0.53 Resin-based Composite

Restorations 166 125 $2.34 $3.51

Periodontal Maintenance 54 48 $0.16 $0.42 Other Orthodontic Services 50 25 $0.41 $0.97

Tests & Examinations 46 27 $0.00 $0.01 Surgical Extractions 39 41 $0.44 $1.03

Non-Surgical Services 35 50 $0.30 $0.73

* Service Type is the procedure detail of Service Category

CITY OF EDINBURG 000243483: ALL

Dental Financial Analysis

Report Description: Provides the dental loss ratio and claims for the most recent reported twelve months.

Month Premium Dental Paid Claims Dental Loss Ratio May 2024 $28,141 $27,310 97.0% Jun 2024 $27,978 $22,227 79.4% Jul 2024 $27,911 $19,161 68.7% Aug 2024 $28,149 $27,398 97.3% Sep 2024 $28,245 $23,818 84.3% Oct 2024 $29,087 $24,791 85.2% Nov 2024 $28,982 $23,084 79.6% Dec 2024 $29,029 $19,717 67.9% Jan 2025 $28,894 $24,290 84.1% Feb 2025 $28,833 $22,518 78.1% Mar 2025 $28,759 $22,505 78.3% Apr 2025 $28,503 $29,500 103.5% Summary $342,510 $286,319 83.6%

Key Findings: The dental loss ratio for the most recent reported month was 19.9% higher than the average of the most recent reported twelve months, which was 83.6%.

CITY OF EDINBURG 000243483: ALL

Dental: Loss Ratio

Certain Conditions Original in the Perinatal Period: Includes infant-related conditions associated with prematurity and the newborn period until one month of age. Example conditions include prematurity, low birth weight, multiple births, various birth-related injuries, respiratory distress syndrome, and jaundice.

Certain Infectious and Parasitic Diseases: Includes communicable or transmissible diseases caused by bacteria and viruses that commonly cause widespread infection.

Example conditions include sepsis, infectious shock, tuberculosis, and COVID-19. Of note: immunization claims, which were previously in this category in the CCS diagnostic category system, are now in the Factors Influencing Health Status category.

Congenital Malformations, Deformations, and Chromosomal Abnormalities: Includes any genetic condition and/or organ malformations present at birth. Example conditions within this category include Down Syndrome, various heart defects, diaphragmatic hernia, spina bifida, cleft palate, polycystic kidney disease, and limb malformations.

Diseases of the Blood and Blood Forming Organs and Certain Disorders Involving the Immune Mechanism: Includes conditions related to white or red blood cells, platelets, or plasma. Example conditions include various types of anemias (e.g., iron deficiency, aplastic, sickle cell) and coagulation disorders such as hemophilia, and various immunodeficiency conditions.

Diseases of the Circulatory System: Includes conditions involving the heart, arteries, and veins. Example conditions within this category include hypertension, heart attack, coronary heart disease, congestive heart failure, arrhythmias, aneurysms, atherosclerosis, blood clots, and stroke.

Diseases of the Digestive System: Includes conditions involving the digestive organs, which includes the mouth, esophagus, stomach, intestines, gall bladder, liver, and pancreas. Example conditions within this category include stomach and intestinal ulcers, acid reflux, gallstones, cirrhosis, autoimmune hepatitis, pancreatitis, appendicitis, and various hernias.

Diseases of the Ear and Mastoid Process: Includes conditions involve in the ears, such as hearing loss, ear infection, earache, and tinnitus. Of note: This category is new within the CCSR system; these conditions were previously included in the Diseases of the Nervous System and Sense Organs category in the CCS system.

Diseases of the Eye and Adnexa: Includes conditions involving the eyes, such as cataracts, myopia, glaucoma, macular degeneration, and conjunctivitis. Of note: This category is new within the CCSR system; these conditions were previously included in the Diseases of the Nervous System and Sense Organs category in the CCS system.

Diseases of the Genitourinary System: Includes conditions involving the kidneys, bladder, and genitalia, including infertility diagnoses. Example conditions within this category include chronic kidney disease, kidney stones, incontinence, endometriosis, ovarian cysts, female and male infertility, and prostate enlargement. Of note: management related to infertility falls within the Pregnancy, Childbirth and the Puerperium category.

Diseases of the Musculoskeletal System: Includes conditions involving the bones, cartilage, joints, muscles, and connective soft tissue. Example conditions include osteoarthritis, osteoporosis, spinal stenosis, spondylosis, intervertebral disc disorders, radiculopathy, rheumatoid arthritis, and lupus.

CITY OF EDINBURG 000243483: ALL

Appendix: ICD Category Definitions

Certain Conditions Original in the Perinatal Period: Includes infant-related conditions associated with prematurity and the newborn period until one month of age. Example conditions include prematurity, low birth weight, multiple births, various birth-related injuries, respiratory distress syndrome, and jaundice.

Certain Infectious and Parasitic Diseases: Includes communicable or transmissible diseases caused by bacteria and viruses that commonly cause widespread infection.

Example conditions include sepsis, infectious shock, tuberculosis, and COVID-19. Of note: immunization claims, which were previously in this category in the CCS diagnostic category system, are now in the Factors Influencing Health Status category.

Congenital Malformations, Deformations, and Chromosomal Abnormalities: Includes any genetic condition and/or organ malformations present at birth. Example conditions within this category include Down Syndrome, various heart defects, diaphragmatic hernia, spina bifida, cleft palate, polycystic kidney disease, and limb malformations.

Diseases of the Blood and Blood Forming Organs and Certain Disorders Involving the Immune Mechanism: Includes conditions related to white or red blood cells, platelets, or plasma. Example conditions include various types of anemias (e.g., iron deficiency, aplastic, sickle cell) and coagulation disorders such as hemophilia, and various immunodeficiency conditions.

Diseases of the Circulatory System: Includes conditions involving the heart, arteries, and veins. Example conditions within this category include hypertension, heart attack, coronary heart disease, congestive heart failure, arrhythmias, aneurysms, atherosclerosis, blood clots, and stroke.

Diseases of the Digestive System: Includes conditions involving the digestive organs, which includes the mouth, esophagus, stomach, intestines, gall bladder, liver, and pancreas. Example conditions within this category include stomach and intestinal ulcers, acid reflux, gallstones, cirrhosis, autoimmune hepatitis, pancreatitis, appendicitis, and various hernias.

Diseases of the Ear and Mastoid Process: Includes conditions involve in the ears, such as hearing loss, ear infection, earache, and tinnitus. Of note: This category is new within the CCSR system; these conditions were previously included in the Diseases of the Nervous System and Sense Organs category in the CCS system.

Diseases of the Eye and Adnexa: Includes conditions involving the eyes, such as cataracts, myopia, glaucoma, macular degeneration, and conjunctivitis. Of note: This category is new within the CCSR system; these conditions were previously included in the Diseases of the Nervous System and Sense Organs category in the CCS system.

Diseases of the Genitourinary System: Includes conditions involving the kidneys, bladder, and genitalia, including infertility diagnoses. Example conditions within this category include chronic kidney disease, kidney stones, incontinence, endometriosis, ovarian cysts, female and male infertility, and prostate enlargement. Of note: management related to infertility falls within the Pregnancy, Childbirth and the Puerperium category.

Diseases of the Musculoskeletal System: Includes conditions involving the bones, cartilage, joints, muscles, and connective soft tissue. Example conditions include osteoarthritis, osteoporosis, spinal stenosis, spondylosis, intervertebral disc disorders, radiculopathy, rheumatoid arthritis, and lupus.

Diseases of the Nervous System: Includes conditions involving the brain, spinal cord, and nerves. Example conditions include multiple sclerosis, sleep apnea, migraine, fibromyalgia, carpal tunnel syndrome, myasthenia gravis, Parkinson’s disease, Guillain-Barre syndrome, and spinal muscular atrophy. Of note: In the CCS system, this category previously included conditions related to the ears and eyes, but those conditions are now reported in the Diseases of the Ear and Mastoid Process and Diseases of the Eye and Adnexa categories, respectively.

Diseases of the Respiratory System: Includes conditions related to the airway and breathing, which includes the nose, bronchial tree, and lungs. Example conditions within this category include respiratory failure, throat infections, sinusitis, bronchitis, asthma, COPD, and pneumonia.

Diseases of the Skin and Subcutaneous Tissue: Includes conditions involving the skin, hair, and nails. Example conditions would be various skin/decubitus ulcers, cellulitis, psoriasis, dermatitis, alopecia, and fungal infections.

Endocrine, Nutritional and Metabolic Diseases: Includes conditions related to immune system functioning, nutrition, metabolism, and function of the endocrine glands, which include the thyroid, pituitary, pancreas, adrenal glands, ovaries, and testes. Example conditions would be diabetes, cystic fibrosis, thyroid disease, malnutrition, obesity, and hyperlipidemia. Of note: The immunodeficiency conditions that were previously reported in this category in the CCS system are now reported in the Diseases of the Blood and Blood Forming Organs and Certain Disorders Involving the Immune Mechanism category.

External Causes of Morbidity: Includes conditions related to accidents and exposure to harmful substances. Examples of conditions include injuries from motor vehicle accidents, exposure to the elements, and wounds from weapons or firearms.

Factors Influencing Health Status and Contact with Health Services: Includes diagnosis codes that are used for preventive screenings, immunizations, contraceptive management, post-operative rehabilitation, monitoring of post-operative organ transplants, and personal or family history of certain hereditary conditions such as cancer and heart disease. Note: Chemotherapy claims technically fall within this CCSR category, but the logic in Blue Insight ignores these codes to ensure that chemotherapy claims are categorized based on the underlying diagnoses they are treating, most of which are in the Neoplasms category. Also note: diagnosis codes for COVID-19 testing were previously reported in the Infectious and Parasitic Diseases category in the CCS system, but they are now reported under the Factors Influencing Health Status category.

Injury, Poisoning and Certain Other Consequences of External Causes: Includes treatment for injuries to the body, including various poisonings, as well as any complications from medical procedures and devices. Example conditions include sprains and strains, fractures, burns, lacerations, various drug or environmental poisonings, and complications from surgery.

Mental, Behavioral, and Neurodevelopmental Disorders: Includes psychiatric and behavioral conditions related to thinking, feeling, social skills or substance abuse. Example conditions include depression, anxiety, schizophrenia, eating disorders, autism, learning disorders, speech delay, Tourette's syndrome, and substance use disorders.

CITY OF EDINBURG 000243483: ALL

Neoplasms: Includes any abnormal growth of cells, either benign or malignant (cancer). Includes various cancer conditions and any abnormal growth of cells, including related chemotherapy, immunotherapy, and radiation therapy services. Example conditions within this category would be Leukemia, Hodgkin’s Disease, breast, lung, prostate, skin, and colon cancers. Of note: Diagnosis codes for personal or family history of cancer (as opposed to an active cancer diagnosis) were previously included in this category in the CCS system, but they are now included in the Factors Influencing Health Status category.

Pregnancy, Childbirth and the Puerperium: Includes vaginal and cesarean deliveries, maternally-related conditions associated with contraception and fertility management, and any complication of pregnancy. Example claims include fertility testing, artificial insemination, tubal ligation, IUD placement, pregnancy-induced hypertension, bleeding related to pregnancy, gestational diabetes, early or threatened labor, ectopic pregnancy, and delivery procedures. Of note: An actual diagnosis of infertility falls in the Diseases of the Genitourinary System category.

Signs, Symptom and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified: Includes abnormal lab results that may suggest, but do not always confirm, a more specific diagnosis, as well as general symptoms for which a more specific diagnosis cannot be found after medical evaluation, which is common for urgent care and emergency room claims. Example conditions include abdominal pain, shortness of breath, chest pain, fainting, nausea, fever, swelling, and abnormal test results. Note: Preventive screening claims were previously included in this category in the CCS system but are now included in the Factors Influencing Health Status category.

CITY OF EDINBURG 000243483: ALL

Admin Fees: The charge to an account for HCSC's operational cost of doing business.

Administrative Services Only (ASO): A contract between HCSC and a self-funded plan where HCSC performs administrative services only and does not assume any financial risk. Services usually include claims processing but may include other services such as actuarial analysis and utilization review.

Aggregate: Constituting or amounting to a whole. For example, an aggregate account report includes data for the entire account.

Aggregate Stop Loss: A form of reinsurance that provides protection for medical expenses above a certain limit, generally on a year-by-year basis. Aggregate stop loss provides protection against the accumulation of total claims for a group as a whole exceeding a stated level.

Allowed: Amount considered eligible for payment by the plan

ASO Adjustments: An amount added or deducted from ASO (Administrative Services Only) fees. This includes Stop Loss Reimbursements.

Average Age: The difference between the claimant's year of enrollment and year of birth. Calculated using the measure Average Age divided by the members represented in the report.

Average Contract Size: The average number of members per subscriber. It is calculated as: Medical Members / Medical Subscribers

Average Dependents: Calculated using the measure Member Months (filtered on the Relationship = Dependents) divided by the number of months in the report.

Average Ingredient Cost: Represents the cost of the medication and is determined from the lowest submission of the pharmacy network rate, Usual & Customary amount, or Maximum Allowable Cost (MAC)

Average Members: Calculated using the measure Member Months divided by the number of months included in the report.

Average Subscribers: Calculated using the measure Subscriber Months divided by the number of months included in the report.

Billed: Amount submitted for payment by the provider

Billing and Accounts Receivable System (BARS): An HCSC financial system where all Administrative Services Only (ASO) customer bills are generated.

Blue Card Access Fee: Interplan Teleprocessing Services fee charged on out-of-state claims for accessing the local plan's provider network

Brand Formulary: Brand name medications that are listed on the formulary

Brand Non-Formulary: Brand name medications that are not listed on the formulary

Claimants: Number of individual members submitting a claim

Claim Lag: The amount of time between the date a claim is incurred and the date the claim payment is made.

CITY OF EDINBURG 000243483: ALL

Glossary

COB: Portion of amount considered eligible for payment that has been paid by another insurance company (Coordination of Benefits)

COB Medicare: Portion of amount considered eligible for payment that has been paid by Medicare

COBRA Members: Consolidated Omnibus Budget Reconciliation Act - A federal law which requires most employers sponsoring group health plans to offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) when coverage under the plan would otherwise end.

Coinsurance: Portion of covered amount member is responsible to pay for the claim

Co-payment: Flat rate that the member is responsible to pay for the claim

Coverage Tier: Eligibility tiers which stratify enrollment data based on the employee and others enrolled under the employee's coverage. Varying benefits can be assigned to tiers.

Covered Amount: Amount eligible for payment based on the terms of the medical/dental benefits agreement.

DAW/1: Indicates that the physician has specified 'do not substitute' on the prescription.

DAW2: Indicates that the Physician has allowed a substitution, but the patient requested brand to be dispensed

Deductible: Portion of annual deductible amount member is responsible to pay applied to the claim.

Dental Loss Ratio: Calculated as the Dental Paid Claims Amount divided by the Billed Dental Premium Amount.

Dental Paid Claims: An amount paid to cover the Health Plan's liability for dental services provided to members for claims that have been processed and approved for payment.

Discount: Amount of reduction from billed amount that has been negotiated with the provider

Discount %: For medical claims, the discount percent is calculated as Discount / Covered

Dispensing Rate: The proportion of total drugs claims a certain drug or drug type is being dispensed

Drug Type: An indicator on each Rx claim that tells whether a prescription is single source brand, multi-source brand or generic item.

Effective Discount %: The effective discount percentage is calculated as: Discount / (Discount + Paid)

Fees and Credits: Includes all account-specific member and account level fees. Can include Specific Stop Loss, Aggregate Stop Loss, Administration, Access Fees, ASO Adjustments (either debits or credits), Rx Credits and other miscellaneous fees.

Females (20-44 years): The total number of members who are women between the ages of 20 and 44 years. The proportion of females (20-44 years) is calculated as: Member Months for Women between 20-44 years / Member Months

Formulary Compliance Rate: The percentage of drugs dispensed that were included in the formulary

CITY OF EDINBURG 000243483: ALL

Generic Dispensing Rate: Proportion of potential generic prescriptions that were filled as generic (excludes COVID claims).

Generic Drugs: A medication for which the patent has expired, allowing any manufacturer to produce and distribute the product under the chemical name.

Generic Substitution Rate: The rate in which generics were dispensed when a generic was available (excludes COVID claims).

Group Liability: Total Claim Expense plus Fees and Credits

HCC: High Cost Claimant, a claimant with total paid amount over a specified threshold (e.g., $30,000 or $50,000) within the reporting period

IBNR: An acronym for 'incurred but not reported'. IBNR claims are that group which are incurred before the fund reserving date, but not reported until after that date.

Ingredient Cost: The cost of the drug including sales tax, excluding dispensing fees.

In-Network Paid %: Percent of total paid expenses for in-network claims. It is calculated as: In-Network Paid / Paid

Inpatient Facility: Refers to Facility Inpatient claims

International Classification of Diseases (ICD): An official list of categories of diseases, physical and mental, issued by the World Health Organization (WHO).

Leading ICD Diagnostic Category: For each patient, summarize total paid amount for each diagnosis and its corresponding MDC. The MDC with the greatest paid amount for the patient becomes the Leading ICD Diagnostic Category for the reporting period

MAC Program Savings: Savings achieved by using the MAC (maximum allowable cost) discount on generic medications

Medical Paid Claims: An amount paid to cover the Health Plan's liability for medical (healthcare) services provided to members for claims that have been processed and approved for payment

Medical/Pharmacy Loss Ratio: Calculated as the combined Medical and Pharmacy Paid Claims Amount divided by the total Billed Premium Amount for Medical and Pharmacy, where appropriate

Member Months: Count of months of eligibility for members

Multi-Source Brand: Brand name medications with a generic equivalent

Network Indicator: An indicator that shows whether the claim was processed as in-network (e.g., in the Preferred Provider Organization network) or out-of-network and paid accordingly

Network Savings Discount: The discount that is applied when a member receives services from a contract provider.

Not Covered: Amount considered not eligible for payment by the plan (excludes the discount amount)

CITY OF EDINBURG 000243483: ALL

Other Adjustments: Minor payments or credits not captured in other specific expense measures

Other Payments: Combination of Blue Card access fees and surcharge expenses

Other Reductions: Combination of maximum reductions, penalties, workers compensation savings, and subrogation savings

Out of Pocket: Total amount that is the responsibility of the claimant. It is calculated as: (Copay + Deductible + Coinsurance)

Outpatient Facility: Refers to Facility Outpatient claims

Paid: Total amount paid by the plan, including access fees, adjustments, and surcharges

Paid-Provider: Amount paid to the provider by the plan

Paid/Claimant: Amount paid to the provider by the plan per claimant. It is calculated as: Paid / Claimants

Paid/Service: Amount paid to the provider by the plan per admission (inpatient facility), per visit (outpatient facility and professional) or per script (prescription Rx).