CITY_OF_EDINBURG_000243483_AL_-_City_of_Edinburg_Utilization_Analysis_(Mar_'23_to_Sept_'23).pdf

Blue Insight℠ Utilization Analysis Report

Incurred_03/01/2023 to 09/30/2023 Paid 03/01/2023 to 11/30/2023

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 2026 Health Care Service Corporation. All rights reserved.

Data Parameters 3

Executive Summary 4

Executive Summary Dashboard 5

Enrollment Overview 6

Key Indicators 7-8

Top Diagnostic Categories 9

Musculoskeletal and Connective Tissue 10

Neoplasms 11

Circulatory 12

Adult Chronic Conditions Analysis 13

High Cost Claimants Overview 14

High Cost Claimants Trend 15

High Cost Claimants Additional Details 16

High Cost Claimants Diagnostic Categories 17

High Cost Claimants Listing 18

Inpatient Facility Overview 19

Inpatient Facility – Details by Service Type 20

PLAN PERFORMANCE

Inpatient Deliveries 21

Inpatient Provider Summary 22

Outpatient Facility Overview 23

Outpatient Facility – Details by Service Type 24

Emergency Room Overview 25

Emergency Room – Leading Diagnoses 26

Frequent Users of the Emergency Room 27

Outpatient Provider Summary 28

Professional Services Overview 29

Professional Services – Details by Service Type 30

Preventive Care 31

Pharmacy Overview 32

Pharmacy: Top Non-Specialty Therapeutic Drug Classes 33

Pharmacy: Specialty Drug Analysis 34

Appendix: Financial Summary 35

Appendix: Glossary 36

CITY OF EDINBURG 000243483: ALL

Table of Contents

Data Parameters 3

Executive Summary 4

Executive Summary Dashboard 5

Enrollment Overview 6

Key Indicators 2 7

Top Diagnostic Categories 8

Adult Chronic Conditions Analysis 9

High Cost Claimants Trend 10

High Cost Claimants Additional Details 11

Inpatient Facility Overview 12

PLAN PERFORMANCE

Outpatient Facility Overview 13

Emergency Room Overview 14

Emergency Room – Leading Diagnoses 15

Frequent Users of the Emergency Room 16

Professional Services Overview 17

Preventive Care 18

Appendix: Glossary 19

CITY OF EDINBURG 000243483: ALL

Table of Contents

Benchmark data is based on Texas group population. Select benchmark utilization and expense measures, such as PMPMs and rates per 1,000, have been adjusted to reflect the group's age and gender distribution.

High Cost Claimants are defined as members with paid expenses greater than $50,000_within the reporting period.

The report includes medical and pharmacy claims.

Reporting Segments: ALL Characteristics: ALL Group/Sections: ALL Member MSA: ALL Group: ALL Medicare Primary Indicator: ALL Funding Type: ALL Product Type: ALL Employee Status: ALL Database(s): CITY OF EDINBURG 000243483: ALL

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 07/02/2026

Current Reporting Period: The current reporting period represents claims incurred from March 1, 2023 through September 30, 2023 and paid March 1, 2023 through November 30, 2023.

Prior Reporting Period: The prior reporting period represents claims incurred from March 1, 2022 through September 30, 2022 and paid March 1, 2022 through November 30, 2022.

CITY OF EDINBURG 000243483: ALL

Data Parameters

CITY OF EDINBURG 000243483: ALL’s overall enrollment remained stable_0.0%_between the two reporting periods. The average age among CITY OF EDINBURG 000243483: ALL’s members increased from 0 to 32.9_years of age. The gender mix of the population was 37.4%_female and 62.6%_male.

The overall paid expense per member per month (PMPM) remained stable_0.0%_between the two reporting periods. The service category that impacted the paid PMPM trend the most was_, which remained stable_0.0%. Additionally, paid PMPM for CITY OF EDINBURG 000243483:

ALL_was_32.1%_lower than_the benchmark.

Inpatient paid PMPM remained stable_0.0%_between reporting periods. The top two admission types by paid PMPM were Medical_and_Surgical. Medical_remained stable_0.0%. Surgical_remained stable_0.0%.

Outpatient paid PMPM remained stable_0.0%_between reporting periods. The top two outpatient facility visit types by paid PMPM were Emergency Room_and Pharmacy & IV Therapy. Emergency Room_remained stable_0.0%._Pharmacy & IV Therapy_remained stable_0.0%.

Professional paid PMPM remained stable_0.0%_between reporting periods. The top two professional service types by paid PMPM were Evaluation & Management_and Pathology & Laboratory. Evaluation & Management_remained stable_0.0%. Pathology & Laboratory_remained stable_0.0%.

CITY OF EDINBURG 000243483: ALL’s overall top four diagnostic categories by paid expense PMPM were_Neoplasms, Health Status, Digestive, and Genitourinary.These four diagnostic categories accounted for 47.2% of the overall paid expenses in the current reporting period.

For high cost claimants the total paid expenses remained stable__between the two reporting periods. HCCs are defined as claimants whose total expense equaled or exceeded $50,000. The number of HCCs also remained stable__from 0_to_11_during the same time frame. The proportion of paid expenses due to high cost claimants increased from 0.0% to 29.5% between reporting periods.

Paid PMPM for Emergency Room (ER) visits remained stable_0.0%_between reporting periods.Total ER visits/1,000 remained stable_0.0%_in the current reporting period and was 1.1%_lower than_the benchmark.

In the current reporting period, primary care physicians (PCP) accounted for 45.0%_of professional office visits compared to 30.4%_for the benchmark. PCPs accounted for 36.2%_of professional office expenses.

Medical paid PMPM remained stable_0.0%_between reporting periods and was_35.3%_lower than_the benchmark.

Pharmacy paid PMPM_remained stable_0.0%_between reporting periods.

CITY OF EDINBURG 000243483: ALL

Executive Summary

Mar 2022 - Sep

Mar 2023 - Sep 2023 % Change Benchmark

Allowed $4,840,373 0.0%

Paid $3,902,182 0.0%

Paid PMPM $319.80 0.0% $470.85

Medical Plan Performance

Plan Share 78.0% 83.3%

In-Network Paid % 99.9% 99.4%

Discount % 74.3% 62.8%

Members 1,743 0.0%

Subscribers 1,092 0.0%

Dependents 651 0.0%

Key Metrics

Paid

PMPM

0.0%

Claimant Distribution % of Total Paid % of Total Unique Members

Dollar Range Prior Current Benchmark Prior Current Benchmark Non-Utilizers 0.0% 0.0% 0.0% 0.0% 26.6% 25.3%

$0-$50K 0.0% 70.5% 58.5% 0.0% 72.9% 73.8%

$50K-$100K 0.0% 8.6% 14.2% 0.0% 0.3% 0.6%

$100K-$300K 0.0% 12.8% 17.9% 0.0% 0.2% 0.3%

$300K and + 0.0% 8.1% 9.4% 0.0% 0.1% 0.1%

HCC Subtotal 0.0% 29.5% 41.5% 0.0% 0.6% 1.0%

Utilization

Cost and Case Mix

High Cost Claimants

Benchmark

CITY OF EDINBURG 000243483: ALL

Executive Summary Dashboard

Reporting Period Mar 2022 - Sep 2022

Mar 2023 - Sep 2023 % Change Benchmark

Benchmark Variance

Average Membership 1,743 0.0% Employee 1,092 0.0% Spouse 116 0.0% Dependent 536 0.0% Average Contract Size 1.6 0.0% 1.8 -13.5% Average Age 32.9 0.0% 35.1 -6.2% Employee 41.2 0.0% 44.6 -7.7% Spouse 44.1 0.0% 47.3 -6.6% Dependent 13.7 0.0% 13.0 5.6%

% Under 30 45.7% 40.6% % 30 to 49 33.8% 32.5% % 50 to 64 19.3% 23.0% % 65+ 1.2% 3.9% Gender % of Males 62.6% 49.7% % of Females 37.4% 50.3% % of Females Ages 20-44 17.4% 20.5%

• Overall, membership remained stable__between reporting periods.

• The average age was 32.9and remained stable__between reporting periods.

• Contract size remained stable__between reporting periods.

• The percentage of females between ages 20 and 44 increased from_0.0% to 17.4%_between reporting periods.

CITY OF EDINBURG 000243483: ALL

Enrollment Overview

The above chart shows the % change from prior period to current period in paid PMPM, the % change in the amount paid per service (cost), and the % change in the number of services per 1,000 (utilization) by service category.

$319.80 Current Paid

PMPM

0.0% Change Year

Over Year

32.1% Lower than Benchmark

Cost Utilization Cost Utilization Cost Utilization

0.0% 0.0% 0.0% 0.0% 0.0%0.0%

Cost Utilization

0.0% 0.0%

Inpatient Facility

Outpatient Facility

Professional

0.0%

PMPM

0.0%

IP PMPM

0.0%

OP PMPM

0.0%

PS PMPM

Pharmacy

0.0%

RX PMPM

CITY OF EDINBURG 000243483: ALL

Key Indicators

• Total medical paid PMPM remained stable_0.0%_in the current reporting period and was35.3%_below_the benchmark.

• Excluding high cost claimants, the total paid PMPM trend was 0.0%.

Service Category Reporting Period

Mar 2022 - Sep 2022

Mar 2023 - Sep 2023 % Change Benchmark

Benchmark Variance

Inpatient Facility

Paid PMPM $38.63 0.0% $92.69 -58.3% Paid PEPM $61.68 0.0% $174.68 -64.7% Allowed PMPM $45.05 0.0% $106.35 -57.6% Admissions/1,000 38.4 0.0% 45.0 -14.8% Days/1,000 121.0 0.0% 239.8 -49.6% Average Length of Stay 3.2 0.0% 5.3 -40.8% Paid/Admission $12,086 0.0% $24,718 -51.1% Paid/Day $3,832 0.0% $4,638 -17.4%

Outpatient Facility

Paid PMPM $108.38 0.0% $127.87 -15.2% Paid PEPM $173.06 0.0% $247.92 -30.2% Allowed PMPM $139.90 0.0% $172.68 -19.0% Visits/1,000 1,249.0 0.0% 1,224.9 2.0% Paid/Visit $1,041 0.0% $1,253 -16.9%

Professional

Paid PMPM $76.40 0.0% $124.94 -38.9% Paid PEPM $121.99 0.0% $246.03 -50.4% Allowed PMPM $102.89 0.0% $163.45 -37.1% Services/1,000 19,186.0 0.0% 19,343.0 -0.8% Paid/Service $48 0.0% $78 -38.4%

Medical Summary

Paid PMPM $223.41 0.0% $345.51 -35.3% Paid PEPM $356.72 0.0% $668.63 -46.6% Allowed PMPM $287.84 0.0% $442.48 -34.9% In-Network Paid % 99.9% 99.4% In-Network Services % 99.0% 98.1% Plan Share % 78.0% 83.3%

Pharmacy

Rx Paid PMPM $96.39 0.0% $125.34 -23.1% Rx Paid PEPM $153.90 0.0% $238.06 -35.4% Rx Allowed PMPM $108.85 0.0% $139.27 -21.8% Prescriptions/Member 10.5 0.0% 12.2 -14.1% Paid/Prescription $111 0.0% $123 -10.4%

Overall Summary

Paid PMPM $319.80 0.0% $470.85 -32.1% Paid PEPM $510.62 0.0% $906.69 -43.7% Allowed PMPM $396.69 0.0% $581.75 -31.8%

CITY OF EDINBURG 000243483: ALL

Key Indicators

Diagnostic Categories with Paid PMPM Mar 2022 - Sep 2022

Mar 2023 - Sep 2023

% Change Benchmark Benchmark Variance

Neoplasms $48.34 0.0% $42.27 14.4%

Health Status $24.68 0.0% $31.63 -22.0%

Digestive $18.20 0.0% $25.08 -27.4%

Genitourinary $14.14 0.0% $16.82 -15.9%

Circulatory $14.10 0.0% $36.24 -61.1%

Symptoms/Ill-Defined $13.99 0.0% $18.76 -25.4%

Pregnancy $12.55 0.0% $11.56 8.6%

Endocrine $10.00 0.0% $12.63 -20.8%

Musculoskeletal $8.85 0.0% $33.89 -73.9%

Respiratory $8.36 0.0% $12.21 -31.5%

All Others $50.19 0.0% $104.42 -51.9%

Total $223.41 0.0% $345.51 -35.3%

• Neoplasms_was the most costly diagnostic category and paid_PMPM _remained stable__ between reporting periods.

• The top 4 diagnostic categories accounted for _47.2%_ of total medical costs in the current period.

• The_Circulatory_category experienced the largest percentage increase in the current period.

CITY OF EDINBURG 000243483: ALL

Top Diagnostic Categories

Reporting Period Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 % Change Benchmark Benchmark

Variance

Inpatient

Paid PMPM $0.00 0.0% $6.03 -100.0%

Admissions/1,000 0.0 0.0% 1.4 -100.0%

Paid/Day $0 $0 0.0% $13,439 -100.0%

Paid/Admission $0 $0 0.0% $53,232 -100.0%

Outpatient

Paid PMPM $0.00 $6.08 0.0% $14.61 -58.4%

Visits/1,000 0.0 102.3 0.0% 146.5 -30.2%

Paid/Visit $0 $714 0.0% $1,197 -40.3%

Professional

Paid PMPM $0.00 $2.77 0.0% $13.26 -79.1%

Services/1,000 0.0 1,056.2 0.0% 2,579.4 -59.1%

Paid/Service $0 $31 0.0% $62 -49.0%

Total Medical

Paid PMPM $0.00 $8.85 0.0% $33.89 -73.9%

Non High Cost $0.00 $5.59 0.0% $21.68 -74.2%

High Cost $0.00 $3.26 0.0% $12.21 -73.3%

Paid/Claimant $0 $467 0.0% $1,121 -58.3%

Claimants/1,000 0.0 132.5 0.0% 175.7 -24.6%

% of Total Medical Paid 0.0% 4.0% 10.5%

Musculoskeletal paid PMPM accounted for 4.0%_of the total medical paid PMPM

Pa id

P M

PM

$0 Spinal Surgery Knee Replacement

Hip Replacement

Prior $0.00 $0.00 $0.00

Current $0.00 $0.00 $0.04

Benchmark $5.15 $1.13 $0.82

M ed ic al

C la im an ts /1

,0

0 Spinal Surgery Knee Replacement

Hip Replacement

Prior 0.0 0.0 0.0

Current 0.0 0.0 0.6

Benchmark 1.1 0.7 0.5

Common Musculoskeletal Surgical Procedures Paid PMPM

Common Musculoskeletal Surgical Procedures Claimants/1,000

CITY OF EDINBURG 000243483: ALL.

Musculoskeletal and Connective Tissue

Variance Inpatient

Paid PMPM $0.00 $2.59 0.0% $8.09 -68.0%

Admissions/1,000 0.0 2.0 0.0% 2.0 -1.8%

Paid/Day $0 $6,317 0.0% $8,379 -24.6%

Paid/Admission $0 $15,792 0.0% $48,432 -67.4%

Outpatient

Paid PMPM $0.00 $35.32 0.0% $22.76 55.2%

Visits/1,000 0.0 75.7 0.0% 69.5 9.0%

Paid/Visit $0 $5,598 0.0% $3,931 42.4%

Professional

Paid PMPM $0.00 $10.43 0.0% $11.42 -8.7%

Services/1,000 0.0 583.2 0.0% 577.8 0.9%

Paid/Service $0 $215 0.0% $237 -9.5%

Total Medical

Paid PMPM $0.00 $48.34 0.0% $42.27 14.4%

Non High Cost $0.00 $2.79 0.0% $8.78 -68.2%

High Cost $0.00 $45.55 0.0% $33.49 36.0%

Paid/Claimant $0 $12,038 0.0% $5,114 >100%

Claimants/1,000 0.0 28.1 0.0% 53.8 -47.8%

% of Total Medical Paid 0.0% 21.6% 13.6%

2.8%_of members had a Neoplasms diagnosis compared to 6.7%_of the book of business members

Breast Cervical Colorectal Endocrine Leukemia Lymphoma Melanoma Non-

Melanoma Prostate Respiratory Claimants 6.1% 0.0% 6.1% 6.1% 0.0% 6.1% 0.0% 0.0% 2.0% 0.0%

Paid 9.1% 0.0% 4.9% 19.2% 0.0% 52.9% 0.0% 0.0% 0.0% 0.0%

CITY OF EDINBURG 000243483: ALL

Neoplasms

Variance

Inpatient

Paid PMPM $0.00 $5.99 0.0% $16.24 -63.1%

Admissions/1,000 0.0 4.9 0.0% 5.5 -10.1%

Paid/Day $0 $3,179 0.0% $7,060 -55.0%

Paid/Admission $0 $14,622 0.0% $35,616 -58.9%

Outpatient

Paid PMPM $0.00 $4.18 0.0% $12.82 -67.4%

Visits/1,000 0.0 80.6 0.0% 80.2 0.6%

Paid/Visit $0 $623 0.0% $1,919 -67.6%

Professional

Paid PMPM $0.00 $3.92 0.0% $7.18 -45.3%

Services/1,000 0.0 1,512.5 0.0% 1,067.7 41.7%

Paid/Service $0 $31 0.0% $81 -61.4%

Total Medical

Paid PMPM $0.00 $14.10 0.0% $36.24 -61.1%

Non High Cost $0.00 $9.57 0.0% $14.18 -32.5%

High Cost $0.00 $4.53 0.0% $22.06 -79.4%

Paid/Claimant $0 $577 0.0% $1,789 -67.7%

Claimants/1,000 0.0 171.0 0.0% 132.8 28.7%

% of Total Medical Paid 0.0% 6.3% 10.4%

Circulatory paid PMPM accounted for 6.3%_of the total medical paid PMPM

Pa id

P M

PM

$0 High Blood Pressure

Gangrene Abnormal Heart Rhythm

Prior $0.00 $0.00 $0.00

Current $2.84 $2.71 $0.44

Benchmark $2.74 $0.33 $1.16

Inpatient Circulatory Top Five Diagnoses by Paid PMPM

CAD Diabetes CHF Hyperlipidemia Hypertension Current 22.6 79.7 3.9 126.9 186.9

Benchmark 15.9 38.8 5.6 63.7 119.4

Common Circulatory Comorbidity: Claimants/1,000

Claimants can be counted in more than one chronic condition category.

CITY OF EDINBURG 000243483: ALL

Circulatory

Mar 2023 - Sep 2023 Benchmark

Benchmark Variance

CHF 2.9 4.4 -35.2%

CAD 18.0 13.3 35.1%

Claimants/1,000 Diabetes 108.6 66.3 63.7%

Hyperlipidemia 179.7 102.5 75.3%

Hypertension 172.5 119.9 43.9%

No Chronic Conditions 671.5 733.7 -8.5%

CHF $33,856 $41,736 -18.9%

CAD $11,563 $20,981 -44.9%

Paid/Claimant Diabetes $5,149 $7,036 -26.8%

Hyperlipidemia $5,041 $4,229 19.2%

Hypertension $4,854 $6,736 -27.9%

No Chronic Conditions $1,368 $1,698 -19.4%

CHF $13.91 $22.12 -37.1%

CAD $29.69 $37.43 -20.7%

Paid PMPM Diabetes $79.85 $95.83 -16.7%

Hyperlipidemia $129.44 $97.15 33.2%

Hypertension $119.64 $145.91 -18.0%

No Chronic Conditions $131.19 $222.26 -41.0%

• Hyperlipidemia_was the most prevalent chronic condition and was above the benchmark.

• CHF_was the most costly chronic condition on a Paid/Claimant basis and was below the benchmark.

* For a member to be included in one of these chronic condition categories, they must be 18 years or older and have had at least two claims for one of the chronic condition categories that were incurred within 180 days of each other and paid within the last 39 months. Paid per claimant and Paid PMPM rates are for those members in each chronic condition category for the most current reporting period. Costs include the total claimant cost and are not limited to the cost of the chronic condition. This report includes medical and pharmacy claims where applicable. Claimants and their claim spend can be counted in more than one chronic condition category in this report. CAD: Coronary Artery Disease; CHF: Chronic Heart Failure.

Per the American Heart Association, three of the seven key health factors that increase the risks for heart disease and stroke include: High Blood Pressure (Hypertension), High Cholesterol (Hyperlipidemia) and High Blood Glucose (Diabetes). The below chart and bar graphs show key metrics for CITY OF EDINBURG 000243483: ALL for five types of chronic conditions* along with comparative data for members who did not have any known type of chronic condition. All data reflects members aged 18 and above.

CITY OF EDINBURG 000243483: ALL

Adult Chronic Conditions Analysis

0.63% Of Membership

1.08%_Benchmark

29.5% of Total Paid

41.5%_Benchmark Accounted for

High Cost Claimants

_prior

0.0% Repeat HCCs 0.0%_Benchmark

$1.2M Total Paid

_K_in prior period

90.9% Employees

60.3%_Benchmark

Average Age

47_Benchmark

27.3% Female

51.2%_Benchmark

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Overview

Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 % Change Benchmark Benchmark Variance High Cost Claimants 11 0.0%

% of Total Members 0.63% 1.08%

HCC Paid $1,151,901 0.0%

% of Total Paid 29.5% 41.5%

Total Paid PMPM $319.80 0.0% $470.85 -32.1%

Non-High cost $225.40 0.0% $282.42 -20.2%

High Cost $94.40 0.0% $188.43 -49.9%

HCC Paid/Claimant $104,718 0.0% $122,305 -14.4%

• 0.63%_of members were high cost claimants in the current period compared to _in the prior period and 1.08%_for the benchmark.

• High cost claimants accounted for_29.5%_of total costs in the current period compared to _in the prior period and 41.5%_for the benchmark.

• Paid PMPM for high cost claimants _remained stable_0.0%_between the two reporting periods and was_49.9%_lower than_the benchmark.

• Paid PMPM excluding high cost claimants remained stable_0.0%_between the two reporting periods and was 20.2%_lower than_the benchmark.

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Trend

• The_$0-$49,999_paid band experienced the largest percent _in paid dollars in the current reporting period.

• 11_claimants accounted for 29.5%_of the total paid amount in the current reporting period.

• By service category, Outpatient Facility_accounted for the largest percent of high cost claimant paid dollars in the current reporting period.

• Employee_accounted for the largest percent of high cost claimant paid dollars in the current reporting period.

Claimant Distribution by Paid Band

Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 % Change Dollar Range Claimants Paid Paid % Claimants Paid Paid % Claimants Paid No Claims 0 $0 0.0% 502 $0 0.0% 0.0% 0.0%

$0-$49,999 0 $0 0.0% 1,377 $2,750,281 70.5% 0.0% 0.0%

$50,000-$99,999 0 $0 0.0% 6 $333,707 8.6% 0.0% 0.0%

$100,000-$299,999 0 $0 0.0% 4 $500,236 12.8% 0.0% 0.0%

$300,000+ 0 $0 0.0% 1 $317,958 8.1% 0.0% 0.0%

HCC Subtotal 0 $0 0.0% 11 $1,151,901 29.5% 0.0% 0.0%

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Additional Details

Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 Top 5 HCC Diagnostic Categories by Paid Claimants Paid Paid/Claimant Paid % Claimants Paid Paid/Claimant Paid % Neoplasms 0 $0 $0 0.0% 5 $669,400 $133,880 58.1%

Blood Diseases 0 $0 $0 0.0% 1 $154,259 $154,259 13.4%

Symptoms/Ill-Defined 0 $0 $0 0.0% 2 $107,342 $53,671 9.3%

Circulatory 0 $0 $0 0.0% 1 $107,165 $107,165 9.3%

Digestive 0 $0 $0 0.0% 1 $62,807 $62,807 5.5%

All others $0 $0 0.0% 1 $50,928 $50,928 4.4%

Summary $0 $0 0.0% 11 $1,151,901 $104,718 100.0%

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Diagnostic Categories

Rank Relationship Age/Gender

Band Leading Diagnostic Category Leading Diagnosis Inpatient Paid Outpatient

Paid Professional

Paid Pharmacy Paid Total Paid Prior HCC Prior Period

Paid

1 Subscriber Male 20-29 Neoplasms Hodgkin lymphoma $0 $309,783 $8,065 $110 $317,958 NO NA

2 Subscriber Male 50-59 Blood Aplastic anemia $86,558 $8,360 $11,046 $48,295 $154,259 NO NA

3 Subscriber Male 50-59 Neoplasms Endocrine system cancers - pancreas $0 $21,073 $93,059 $12,837 $126,969 NO NA

4 Subscriber Female 50-59 Neoplasms Multiple myeloma $0 $9,497 $1,219 $101,127 $111,843 NO NA

5 Subscriber Male 65+ Circulatory Gangrene $49,213 $36,773 $12,402 $8,778 $107,166 NO NA

6 Subscriber Male 60-64 Digestive Biliary tract disease $50,127 $4,260 $7,773 $648 $62,808 NO NA

7 Spouse Female 40-49 Neoplasms Breast cancer - all other types $0 $46,548 $10,934 $14 $57,496 NO NA

8 Subscriber Male 40-49 Neoplasms Gastrointestinal cancers - colorectal $0 $50,165 $4,573 $394 $55,132 NO NA

9 Subscriber Female 50-59 Symptoms/Ill-Defined Respiratory signs and symptoms $0 $127 $1,808 $52,078 $54,013 NO NA

10 Subscriber Male 20-29 Symptoms/Ill-Defined Nausea and vomiting $0 $173 $503 $52,653 $53,329 NO NA

11 Subscriber Male 40-49 Not Available Not Available $0 $0 $0 $50,928 $50,928 NO NA

* NA : member was not enrolled in prior period

CITY OF EDINBURG 000243483: ALL

High Cost Claimants Listing

Variance

Medical Pharmacy Paid

PMPM $0.00 $43.62 0.0% $50.51 -13.6%

Non High Cost $0.00 $11.56 0.0% $17.09 -32.3%

High Cost $0.00 $32.06 0.0% $33.42 -4.1%

Paid/Claimant $0 $989 0.0% $1,235 -19.9%

Claimants/1,000 0.0 308.6 0.0% 272.3 13.4%

Special Medical Pharmacy Paid PMPM $0.00 $31.38 0.0% $28.95 8.4%

Gene and Cell Therapy Paid

PMPM $0.00 0.0% $1.00 -100.0%

Med Rx as % of Total Paid 0.0% 19.5% 13.9%

• Total paid PMPM for Medical Pharmacy remained stable at0.0% in the current reporting period and was 13.6%below the benchmark.

• Neoplasms was the most costly diagnostic category for Medical Pharmacy and paid PMPM remained stable at0.0% between reporting periods.

• J9299 - OPDIVO was the most costly drug for Medical Pharmacy and paid PMPM remained stable at0.0% between reporting periods.

Medical Pharmacy Paid PMPM by Top-3 Diagnostic Categories

Medical Pharmacy Paid — PMPM Top-5 Drugs*

Neoplasms accounted for 68.1% of the total Medical Pharmacy Paid PMPM in the current period.

*Leading diagnostic category for each drug is listed under drug name.

Pa id

P M

PM

$0.00 J9299 - OPDIVO

Neoplasms

Q5108 - FULPHILA

Neoplasms

J9042 - ADCETRIS

Neoplasms

J9206 - CAMPTOSAR

Neoplasms

J2350 - OCREVUS

Nervous

Current $9.29 $6.92 $3.81 $3.32 $3.10

Benchmark $1.33 $0.45 $0.72 $0.11 $1.33 Pa id P

M

PM

$0.00 Neoplasms Nervous

Prior $0.00 $0.00 $0.00

Current $0.00 $29.69 $3.20

Benchmark $0.00 $17.40 $5.10

Report Description: Medical Pharmacy applies only to drugs paid under the Medical Plan.

CITY OF EDINBURG 000243483: ALL.

Medical Pharmacy

• Inpatient paid PMPM remained stable__between the two reporting periods and was 58.3%_lower than_the benchmark.

• High Cost Claimants accounted for 39.4%_of total inpatient spend compared to 0.0%_from the previous reporting period.

• Admissions/1,000 remained stable__between reporting periods and was 14.8%_lower than_the benchmark.

• Digestive_was the most costly diagnostic category for inpatient services in the current reporting period. It increased_>100%_and was 6.8%_lower than_ the benchmark.

Reporting Period Mar 2022 - Sep 2022

Mar 2023 - Sep 2023 % Change Benchmark

Benchmark Variance

Allowed $549,742 0.0% Allowed PMPM $45.05 0.0% $106.35 -57.6% Paid $471,360 0.0% Paid PEPM $61.68 0.0% $174.68 -64.7% Paid PMPM $38.63 0.0% $92.69 -58.3% Non-High Cost $23.39 0.0% $26.15 -10.5% High Cost $15.24 0.0% $66.54 -77.1%

Admissions 39 0.0% Admissions/1,000 38.4 0.0% 45.0 -14.8% Days/1,000 121.0 0.0% 239.8 -49.6% Average Length of Stay 3.2 0.0% 5.3 -40.8% Paid/Admission $12,086 0.0% $24,718 -51.1% In-Network Paid % 100.0% 99.5% In-Network Admissions % 100.0% 98.9%

CITY OF EDINBURG 000243483: ALL

Inpatient Facility Overview

Inpatient Paid PMPM by Service Type Inpatient Admissions/1,000 by Service Type

Inpatient Paid/Admission by Service Type Inpatient Average Length of Stay (ALOS) by Service Type2023

Ad m iss io ns /1

,0

0 Medical Maternity Surgical Complex Newborns

Mental Health

Prior 0.0 0.0 0.0 0.0

Current 14.8 10.8 6.9 3.9 2.0

Benchmark 14.9 9.9 9.3 4.2 5.4

Pa id

P M

PM

$0 Medical Surgical Maternity Complex Newborns

Mental Health

Prior $0.00 $0.00 $0.00 $0.00

Current $16.78 $13.74 $6.79 $0.94 $0.38

Benchmark $26.18 $43.29 $7.70 $7.21 $4.16

AL

O

S

0 Medical Surgical Mental Health Complex Newborns

Maternity

Prior 0.0 0.0 0.0 0.0

Current 3.7 3.7 3.0 2.5 2.3

Benchmark 4.2 5.0 11.0 5.3 2.6

Pa id

/ A dm iss io n

$0 Surgical Medical Maternity Complex Newborns

Mental Health

Prior $0 $0 $0 $0

Current $23,954 $13,648 $7,527 $2,877 $2,326

Benchmark $55,988 $21,143 $9,336 $20,773 $9,195

CITY OF EDINBURG 000243483: ALL

Inpatient Facility - Details by Top 5 Service Types

Normal Delivery and C-Section Overview:

Paid PMPM Admissions/1,000 Paid/Admission

Reporting Period Mar 2022 - Sep 2022

Mar 2023 - Sep 2023 % Change Benchmark

Benchmark Variance

Paid $71,667 0.0%

Paid PMPM $5.87 0.0% $6.67 -11.9%

Admissions 11 0.0%

C-Section Delivery 3 0.0%

Normal Delivery 8 0.0%

Admissions/1,000 10.8 0.0% 9.2 17.4%

Days/1,000 24.6 0.0% 23.7 3.6%

Average Length of Stay 2.3 0.0% 2.6 -11.7%

C-Section Delivery 2.7 0.0% 3.3 -18.8%

Normal Delivery 2.1 0.0% 2.2 -3.2%

Paid/Admission $6,515 0.0% $8,684 -25.0%

Average Mother Age 28.4 0.0% 30.5 -7.1%

The C-Section rate was 27%_which is below _the benchmark (36%) .

$0 Normal Delivery C-Section Delivery

Prior $0 $0

Current $5,711 $8,660

Benchmark $7,133 $11,602

0 Normal Delivery C-Section Delivery

Prior 0.0 0.0

Current 7.9 3.0

Benchmark 6.0 3.2

$0.00 Normal Delivery C-Section Delivery

Prior $0.00 $0.00

Current $3.74 $2.13

Benchmark $3.58 $3.09

CITY OF EDINBURG 000243483: ALL

Inpatient Deliveries

Mar 2023 - Sep 2023

Top Inpatient Providers by Admissions

Provider State

Admissions Paid % of Total Paid

Paid/ Admission

MCALLEN HOSPITALS L P TX 17 $213,488 45.3% $12,558.13

DOCTORS HOSPITAL AT RENAISSANCE, LTD TX 17 $180,807 38.4% $10,635.73

VHS HARLINGEN HOSPITAL COMPANY LLC TX 1 $24,476 5.2% $24,476.02

UNIVERSITY OF TEXAS M. D. ANDERSON CANCER CENTER TX 1 $15,784 3.4% $15,784.00

COLUMBIA RIO GRANDE HEALTHCARE, L.P. TX 1 $14,212 3.0% $14,212.23

VHS HARLINGEN HOSPITAL COMPANY, LLC TX 1 $13,581 2.9% $13,580.58

MISSION HOSPITAL, INC. TX 1 $9,011 1.9% $9,011.22

All Other 0.0% $0.00

Summary 39 $471,360 100.0% $12,086.15

• MCALLEN HOSPITALS L P_was the most frequently utilized inpatient facility.

• The top inpatient facility by paid amount was_MCALLEN HOSPITALS L P, which accounted for 45.3% of the total inpatient paid amount in the current reporting period.

• The top 10 inpatient providers accounted for 100.0%_of the total inpatient spend in the current reporting period._

CITY OF EDINBURG 000243483: ALL

Inpatient Provider Summary

Sep 2022

Mar 2023 - Sep 2023 % Change Benchmark

Benchmark Variance

Allowed $1,707,007 0.0% Allowed PMPM $139.90 0.0% $172.68 -19.0% Paid $1,322,506 0.0% Paid PEPM $173.06 0.0% $247.92 -30.2% Paid PMPM $108.38 0.0% $127.87 -15.2% Non-High Cost $68.49 0.0% $80.40 -14.8% High Cost $39.89 0.0% $47.47 -16.0%

Visits 1,270 0.0% Visits/1,000 1,249.0 0.0% 1,224.9 2.0% Paid/Visit $1,041 0.0% $1,253 -16.9% In-Network Paid % 100.0% 99.5% In-Network Visits % 99.8% 98.1%

• Outpatient paid PMPM remained stable__between the two reporting periods and was 15.2%_ lower than_the benchmark.

• High Cost Claimants accounted for 36.8%_of total outpatient spendcompared to 0.0%_from the previous reporting period.

• Neoplasms_was the most costly diagnostic category for outpatient services in the current reporting period. It increased_>100%_and was 55.2%_ higher than_the benchmark.

CITY OF EDINBURG 000243483: ALL

Outpatient Facility Overview

Outpatient Paid PMPM by Service Type

Outpatient Visits/1,000 by Service Type Outpatient Paid/Visit by Service Type

• Emergency Room_was the service type with the highest paid PMPM for outpatient services in the current reporting period. Paid PMPM increased_0.0%_and was 1.3%_higher than_the benchmark.

• Pathology & Laboratory_had the highest rate of visits/1,000 in the current reporting period.

• Pharmacy & IV Therapy_had the highest amount paid per visitin the current reporting period.

Pa id

P M

PM

$0 ER Pharmacy & IV Therapy

Pathology & Laboratory

Surgical Radiology

Prior $0.00 $0.00 $0.00 $0.00 $0.00

Current $29.28 $24.19 $17.04 $16.80 $16.36

Benchmark $28.90 $13.93 $4.45 $49.34 $14.46

Vi sit s/ 1, 0 Pathology & Laboratory

ER Radiology Other Outpatient

Services

Surgical

Prior 0.0 0.0 0.0 0.0 0.0

Current 531.1 217.3 163.3 84.6 76.7

Benchmark 207.8 219.8 182.4 95.5 113.7

Pa id

/ V isi t

$0 Pharmacy & IV Therapy

Surgical ER Radiology Observation

Prior $0 $0 $0 $0 $0

Current $4,277 $2,629 $1,617 $1,202 $735

Benchmark $3,943 $5,209 $1,578 $951 $1,572

CITY OF EDINBURG 000243483: ALL

Outpatient Facility - Details by Top 5 Service Types

• ER paid PMPM_remained stable _0.0%_between the two reporting periods and was 1.3%_higher than_the benchmark.

• ER visits/1,000 remained stable _0.0%_between reporting periods and was 1.1%_ lower than_the benchmark.

• Spouses_had the highest ER visits/1,000 rate in the current period.

ER Visits/1,000 by Relationship

Mar 2022 - Sep 2022

Mar 2023 - Sep 2023 % Change Benchmark

Benchmark Variance

ER Allowed $569,174 0.0% ER Paid $357,270 0.0% ER Allowed PMPM $46.65 0.0% $43.47 7.3% ER Paid PMPM $29.28 0.0% $28.91 1.3% ER Visits 221 0.0% ER Visits/1,000 217.3 0.0% 219.8 -1.1% ER Allowed/Visit $2,575 0.0% $2,373 8.5% ER Paid/Visit $1,617 0.0% $1,578 2.4% % of ER Claimants with 3+ Visits 4.7% 6.5%

Total ER Allowed/Visit* $2,971 0.0% $2,755 7.9% Total ER Paid/Visit* $1,793 0.0% $1,827 -1.8%

*Includes physician charges

Mar 2022 - Sep 2022

Mar 2023 - Sep 2023 % Change Benchmark

Benchmark Variance

Employee 219.8 0.0% 233.5 -5.9%

Spouse 296.7 0.0% 250.3 18.5%

Dependent 195.1 0.0% 209.3 -6.8%

CITY OF EDINBURG 000243483: ALL

Emergency Room Overview

Top ER Diagnoses for Mar 2023 - Sep 2023

ER Diagnosis Paid Claimants Visits %Visits Potentially

Non-Emergent * Injury/Poisoning $45,245 34 35 0.0%

Digestive $50,979 25 30 46.7%

Symptoms/Ill-Defined $42,581 27 30 43.3%

Genitourinary $34,736 15 19 89.5%

Infectious/Parasitic $31,401 16 16 6.3%

Circulatory $32,980 11 14 0.0%

Respiratory $23,375 12 14 71.4%

Musculoskeletal $16,737 10 10 40.0%

Nervous $11,373 9 9 22.2%

Pregnancy $11,553 5 7 0.0%

All Others $56,310 35 37 24.3%

Summary $357,270 171 221 31.7%

• 31.7%_of ER visits were potentially non-emergent in the current reporting period compared to _in the prior reporting period and 27.6%_for the benchmark.

• The conditions with the highest volume of ER visits in the current reporting period were_Injury/Poisoning_, _Digestive_, and _Symptoms/Ill-Defined.

* Not reflective of benefit design

CITY OF EDINBURG 000243483: ALL

Emergency Room Leading Diagnoses

• 5%_of ER claimants visited the ER three or more times in the current reporting period compared to _in the prior reporting period and 6%_for the benchmark.

• Claimants with 3 or more ER visits accounted for 12%_of the ER paid expenses in the current reporting period compared to__in the prior reporting period and 22%_for the benchmark.

ER Visits Claimants Claimants % of Total ER Visits ER Paid 1 133 77.8% 133 $212,106

2 29 17.0% 58 $101,711

3 6 3.5% 18 $29,138

4 1 0.6% 4 $2,353

8 1 0.6% 8 $11,962

10+

Summary 171 100% 221 $357,270

ER Utilization and Costs by Number of Visits for Mar 2023 - Sep 2023

Diagnosis ER Paid ER Visits Claimants Respiratory $11,225 4 3

Genitourinary $9,420 6 3

Digestive $8,512 7 4

Symptoms/Ill-Defined $3,048 2 2

Injury/Poisoning $2,959 3 2

Top Diagnoses of Claimants with 3+ ER Visits for Mar 2023 - Sep 2023

CITY OF EDINBURG 000243483: ALL

Frequent Users Of The Emergency Room

Mar 2023 - Sep 2023

Top Outpatient Providers by Visits

Provider State

Visits Paid % of Total Paid

Paid/ Visit

DOCTORS HOSPITAL AT RENAISSANCE, LTD TX 704 $643,929 48.7% $914.67

MCALLEN HOSPITALS L P TX 231 $296,912 22.5% $1,285.33

HARLINGEN VAMC TX 122 $57,622 4.4% $472.31

COLUMBIA RIO GRANDE HEALTHCARE, L.P. TX 68 $84,142 6.4% $1,237.39

UNIVERSITY OF TEXAS M. D. ANDERSON CANCER CENTER TX 31 $128,567 9.7% $4,147.32

MISSION HOSPITAL, INC. TX 16 $25,150 1.9% $1,571.90

DRISCOLL CHILDRENS HOSPITAL TX 16 $22,700 1.7% $1,418.72

IPH HOME HEALTH CARE INC TX 11 $1,387 0.1% $126.09

ENDOSCOPY CENTER AT RIDGE PLAZA LP TX 9 $6,244 0.5% $693.82

VERGE HOME CARE,LLC TX 8 $717 0.1% $89.57

All Other 54 $55,136 4.2% $1,021.04

Summary 1,270 $1,322,506 100.0% $1,041.34

• DOCTORS HOSPITAL AT RENAISSANCE, LTD_was the most frequently utilized outpatient facility.

• The top outpatient facility by paid amount was DOCTORS HOSPITAL AT RENAISSANCE, LTD, which accounted for 48.7%_of the total outpatient paid amount in the current reporting period.

• The top 10 outpatient providers accounted for 95.8%_of the total outpatient spend in the current reporting period.

CITY OF EDINBURG 000243483: ALL

Outpatient Provider Summary

Sep 2022

Mar 2023 - Sep 2023 % Change Benchmark

Benchmark Variance

Allowed $1,255,459 0.0%

Allowed PMPM $102.89 0.0% $163.45 -37.1%

Paid $932,211 0.0%

Paid PEPM $121.99 0.0% $246.03 -50.4%

Paid PMPM $76.40 0.0% $124.94 -38.9%

Non-High Cost $63.99 0.0% $93.15 -31.3%

High Cost $12.41 0.0% $31.79 -61.0%

Visits/1,000 7,474.2 0.0% 8,904.4 -16.1%

Services/1,000 19,186.0 0.0% 19,343.0 -0.8%

Paid/Visit $123 0.0% $168 -27.2%

Paid/Service $48 0.0% $78 -38.4%

In-Network Paid % 99.8% 99.3%

In-Network Visits % 98.9% 98.0%

• Professional paid PMPM remained stable__between the two reporting periods and was 38.9%_ lower than_the benchmark.

• High Cost Claimants accounted for 16.2%_of total professional spend compared to 0.0%_from the previous reporting period.

• Health Status_was the most costly diagnostic category for professional services in the current reporting period.

It increased_>100%_and was 36.3%_lower than_the benchmark.

• Primary Care Physicians accounted for_45.0%_of the total professional visitsin the current reporting period.

CITY OF EDINBURG 000243483: ALL

Professional Services Overview

Professional Paid PMPM by Service Type

Professional Services/1,000 by Service Type Professional Paid/Service by Service Type

• Evaluation & Management_was the service type with the highest paid PMPM for professional services in the current reporting period. Paid PMPM increased_0.0%_and was 19.0%_lower than_the benchmark.

• Evaluation & Management_had the highest rate of services/1,000 in the current reporting period.

• Anesthesia_had the highest amount paid per service in the current reporting period.

Pa id

P M

PM

$0 Evaluation & Management

Pathology & Laboratory

Medical Services & Supplies

(HCPCS II)

Medical Surgical

Prior $0.00 $0.00 $0.00 $0.00 $0.00

Current $41.26 $8.81 $6.96 $6.65 $4.49

Benchmark $50.95 $6.58 $24.31 $14.02 $14.28

Se rv ic e/

1, 0 Evaluation & Management

Pathology & Laboratory

Medical Radiology PT/OT/ST

Prior 0.0 0.0 0.0 0.0 0.0

Current 10,244.6 5,473.9 1,291.3 651.0 568.4

Benchmark 8,640.9 4,042.5 2,213.4 712.5 1,623.1

Pa id

/ S er vi ce

$0 Anesthesia Medical Services & Supplies

(HCPCS II)

Surgical PT/OT/ST Medical

Prior $0 $0 $0 $0 $0

Current $353 $178 $135 $64 $62

Benchmark $588 $269 $186 $27 $76

CITY OF EDINBURG 000243483: ALL

Professional - Details by Top 5 Service Types

Cancer Screenings:

Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 Benchmark Cervical Cancer Screening 18.2% 16.2%

Colorectal Cancer Screening 7.2% 8.3%

Mammogram Screening 22.0% 25.9%

PCP Care:

Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 Benchmark Annual Physical 18.1% 24.6%

Childhood Immunizations 58.3% 65.9%

Well Infant Care 64.0% 81.3%

Well Young Child Care 58.2% 62.0%

Well School-Age Child Care 44.4% 42.6%

Percentages represent utilization of preventive services by those members for which the service is deemed appropriate.

Compliance rates for well infant care, well young child care,well school-age child care, and childhood immunizations are based on utilization for claimants (not members) for whom the service is deemed appropriate, in order to account for newborn children who have little to no enrollment data.

CITY OF EDINBURG 000243483: ALL

Preventive Care

Metric Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 % Change Benchmark

Variance

Paid $1,176,105 0.0%

Paid PMPM $0.00 $96.39 0.0% $125.34 -23.1%

Member Cost Share % 0.0% 11.7% 10.1%

Paid/Claimant $0.00 $1,063.39 0.0% $1,216.30 -12.6%

Paid/Day $0.00 $4.48 0.0% $5.51 -18.6%

Prescriptions 10,639 0.0%

Prescriptions/1000 0.0 10,462.9 0.0% 12,186.7 -14.1%

Claimants 1,106 0.0%

Claimants/1000 0.0 634.5 0.0% 673.7 -5.8%

Scripts/Claimant 0.0 9.6 0.0% 9.5 0.7%

Generic Dispensing Rate 0.0% 83.8% 87.1%

Rx Retail as % of Prescriptions 0.0% 99.6% 97.1%

Rx Mail Order as % of Prescriptions 0.0% 0.4% 2.9%

Specialty % of Total Prescriptions 0.0% 0.5% 0.7%

Specialty % of Pharmacy Cost 0.0% 31.2% 45.9%

• Pharmacy Paid PMPM_remained stable__and was 23.1%_ below_the benchmark in the current period.

• Prescriptions/1000 remained stable__and was 14.1%_ below_the benchmark.

• The Generic Dispensing Rateremained stable__to 83.8%_and was 3.3%_ lower than_the benchmark.

• Specialty Drugs accounted for 31.2% of the pharmacy spend in the current period compared to 0.0%_in the prior period and 45.9%_in the benchmark.

Generic Dispensing Rate (GDR) vs. Benchmark

CITY OF EDINBURG 000243483: ALL

Pharmacy Overview

Top 10 Non-Specialty Drugs by Ingredient Cost: Current Period

Current/ Prior Rank Drug Product 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 OZEMPIC Incretin Mimetic Agents 220 51 $176,448 $802.04 NO 8

2 MOUNJARO Incretin Mimetic Agents 102 23 $96,799 $949.01 NO 21

3 TRULICITY Incretin Mimetic Agents 75 14 $63,207 $842.76 NO 27

4 JARDIANCE Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 125 31 $63,152 $505.22 NO 17

5 RYBELSUS Incretin Mimetic Agents 39 9 $32,743 $839.56 NO 60

6 FARXIGA Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 55 11 $28,137 $511.59 NO 46

7 TRESIBA FLEXTOUCH Insulin 79 18 $23,877 $302.24 NO 25

8 XIGDUO XR Antidiabetic Combinations 48 12 $23,170 $482.71 NO 48

9 SYNJARDY XR Antidiabetic Combinations 56 13 $20,909 $373.38 NO 44

10 SYNJARDY Antidiabetic Combinations 44 10 $20,001 $454.57 NO 56

All Other 9,747 1,101 $369,522 $37.91 $0

Summary 10,590 1,105 $917,966 $86.68 $0

Top 10 Non-Specialty Drug Classes by Ingredient Cost: Current Period

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 Incretin Mimetic Agents 442 94 $375,454 $849.44 $0 4

2 Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors 192 43 $97,661 $508.65 $0 15

3 Antidiabetic Combinations 227 47 $96,263 $424.07 $0 7.9% 13

4 Insulin 130 26 $44,936 $345.66 $0 24

5 Sympathomimetics 125 93 $16,910 $135.28 $0 59.2% 26

6 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors 30 7 $15,099 $503.31 $0 72

7 Cardiovascular Agents Misc. - Combinations 26 4 $14,636 $562.91 $0 79

8 Digestive Enzymes 8 2 $13,528 $1,690.97 $0 119

9 Direct Factor Xa Inhibitors 26 7 $12,860 $494.63 $0 80

10 Amphetamines 57 13 $11,467 $201.18 $0 59.7% 42

All Other 9,327 1,093 $219,153 $23.50 $0 92.8%

Summary 10,590 1,105 $917,966 $86.68 $0 82.9%

CITY OF EDINBURG 000243483: ALL

Pharmacy: Top Non-Specialty Therapeutic Drug Classes

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 a specialty drug analysis overview.

Top 10 Specialty Drugs by Ingredient Cost for the Year to Date

Brand Name Specialty Class Ingredient

Cost Prescriptions

Avg. Ingredient Cost/

Prescription Specialty Claimants

REVLIMID CAP 25MG CANCER $101,102 6 $16,850.32 1

ENBREL SRCLK INJ 50MG/ML AUTOIMMUNE $60,526 9 $6,725.07 2

TREMFYA INJ 100MG/ML AUTOIMMUNE $51,528 4 $12,881.89 1

CABOMETYX TAB 40MG CANCER $47,014 2 $23,506.99 1

TALTZ INJ 80MG/ML AUTOIMMUNE $25,450 2 $12,724.92 1

DUPIXENT INJ 300/2ML AUTOIMMUNE $20,666 6 $3,444.40 1

TALTZ INJ 80MG/ML AUTOIMMUNE $19,087 1 $19,087.39 1

ACTEMRA INJ ACTPEN AUTOIMMUNE $18,176 8 $2,272.06 1

NORDITROPIN INJ 10/1.5ML GROWTH HORMONES $14,651 2 $7,325.29 1

COSENTYX PEN INJ 300DOSE AUTOIMMUNE $13,419 2 $6,709.61 1

All Other $36,957 7 $5,279.54 6 Summary $408,576 49 $8,338.28 14

Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 % Change Benchmark Benchmark

Variance

Unique Pharmacy Members 1,890 0.0%

Claimants 14 0.0%

Percent of Utilizing Members 0.7% 1.0%

Prescriptions 49 0.0%

Specialty Percent of Total Paid 31.3% 45.9%

Percent of Total Prescriptions Paid 0.5% 0.7%

Paid $367,509 0.0%

Paid PMPM $30.12 0.0% $57.23 -47.4%

Average Ingredient Cost/Prescription $8,338 0.0% $8,960 -6.9%

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

CITY OF EDINBURG 000243483: ALL

Pharmacy: Specialty Drug Analysis

Demographics

Members Current Period

Prior Period

Number of

Procedur es/1000

Prior Year Number of Procedure s/1000

% change Benchmar k Variance

Employee 0.0% 2,833 -100.0%

Spouse 0.0% 3,185 -100.0%

Dependent 0.0% 4,169 -100.0%

Totals

• Membership remained stable by_0.0%_from the previous reporting period, while the number of procedures remained stable by_0.0%_ for the same time period._

• of Total Members utilized their benefit during the current reporting period.

• DIAGNOSTICprocedures accounted for 0% of the total procedures for the account. Compared to from the previous reporting period.

CITY OF EDINBURG 000243483: ALL

Dental Utilization Overview

• The_total paid amount remained stable_0.0%_between reporting periods.

• Total in-network discounts(excluding Medicare) were $10,514,929_(73.8%)_for the current reporting period.

• The in-network paid percentage (excluding Medicare) was 99.8%_for the current reporting period.

Network Overview Mar 2023 - Sep 2023

Financial Order of Reduction (including Pharmacy)

Mar 2022 - Sep 2022 Mar 2023 - Sep 2023 % Change Billed $18,254,599 0.0%

Not Covered $1,512,916 0.0%

Covered $16,741,683 0.0%

Discount $11,634,399 0.0%

Allowed $5,107,284 0.0%

Out of Pocket $965,894 0.0%

COB $66,537 0.0%

COB Medicare $899 0.0%

Other Reductions $1,820 0.0%

Other Adjustments ($18,507) 0.0%

Paid - Provider $4,090,640 0.0%

Other Payments $3,458 0.0%

Total Paid $4,094,098 0.0%

Allowed PMPM $418.56 0.0%

Paid PMPM $335.53 0.0%

Plan Share 80.9% 0.0%

Medicare Primary Indicator Network Indicator Covered Discount Discount % Paid % of Paid

No In-Network $14,251,877 $10,514,929 73.8% $2,903,843 99.8%

Out of Network $53,730 $33,516 62.4% $4,929 0.2%

Yes In-Network $2,531 $59 $210 0.0%

Out of Network $913 $0 $0 0.0%

Summary $14,309,052 $10,548,504 73.7%* $2,908,982 100.0%

Claims on paid basis

*Calculated discount percent excludes Medicare Primary.

CITY OF EDINBURG 000243483: ALL

Appendix: Financial Summary

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

Appendix: 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

Appendix: Glossary

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: Savingsachieved 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

Appendix: Glossary

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.