COE_-_HCC_with_No_PHI_md.pdf
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- Attached to
- Pharmacy Benefits 2025-2026
- Solicitation number
- 2025-011
- Issued by
- Hidalgo County, Texas
About this file
This document is a Cost of Evidence (COE) High Cost Claimant (HCC) report for the City of Edinburg, covering pharmacy and medical claims data for 14 claimants from October 2024 to May 2025. The report provides a comprehensive breakdown of healthcare utilization and costs across various service categories including inpatient, outpatient, professional services, and pharmacy, with a high-cost threshold of $50,000. The claimants represent different age groups, genders, and relationships (subscribers, spouses, and dependent children) enrolled in PPO and HMO benefit packages.
The total paid medical costs for these 14 claimants are $1,754,648.87, with significant variation in individual claims ranging from $52,129.13 to $384,163.23. The primary diagnoses include a wide range of medical conditions such as non-Hodgkin's lymphoma, multiple sclerosis, bone cancer, and various other diseases across different medical categories. The report details paid amounts for medical services, including inpatient, outpatient, professional, emergency room, and pharmacy costs, along with specific prescription medications, IP admissions, IP days, outpatient visits, and professional visits for each claimant.
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Text version
COE - HCC with No PHI
Run Date: 7/8/2025
Metrics:
Database:
High Cost
Threshold:
Paid Month:
Service
Category:
Claimant ID Member
Age/Gender
Band
Member
Relationship
Description
Currently
Enrolled
Indicator
Benefit
Package
Paid Medical Paid IP Paid OP Paid Prof Paid ER Paid Pharmacy
Paid
Primary
Diagnosis
Primary
CCSR Dx
Level 2
Primary
CCSR Dx
Level 1
IP
Admissions
IP Days OP Visits ER Visits Professional
Visits
Prescriptions Primary Drug
Claimant 1 Male 40-49 Subscriber Yes PPO ACTIVE 384,163.23 371,950.94 295,906.67 47,785.89 28,258.38 5,780.00 12,212.29 C83 - Diffuse non-Hodgkin's lymphoma
Non-Hodgkin lymphoma
Neoplasms 8 52 18 2 114 55FULPHILA INJ 6/0.6ML
Claimant 2 Male 40-49 Spouse Yes PPO ACTIVE 227,525.21 226,127.69 81,341.49 131,459.23 13,326.97 12,193.97 1,397.52 Z51 - Other medical care
Bone cancer Neoplasms 2 12 9 1 36 4PAXLOVID TAB 300-100
Claimant 3 Male 40-49 Subscriber Yes PPO ACTIVE 169,108.00 169,003.02 0.00 86,509.72 82,493.30 0.00 104.98 G35 - Multiple sclerosis
Multiple sclerosis
Diseases of the Nervous
System
3 4 5MODAFINIL TAB 100MG
Claimant 4 Male <1-19Dependent Child No PPO ACTIVE 151,384.23 151,384.23 149,393.24 0.00 1,990.99 0.00 0.00 P07 -
Disorders related to short gestation and low birth weight, not elsewhere classified
Short gestation; low birth weight;
and fetal growth retardation
Certain
Conditions
Originating in the Perinatal
Period
1 13 16
Claimant 5 Female 50-59 Subscriber YesPPO RETIREE PRE 65 140,986.04 13,375.39 0.00 11,739.58 1,635.81 0.00 127,610.65 Z08 - Follow-up examination after treatment for malignant neoplasms
Neoplasm-related encounters
Factors
Influencing
Health Status and Contact with Health
Services
6 27 19REVLIMID CAP 10MG
Claimant 6 Female <1-19Dependent Child Yes PPO ACTIVE 110,936.03 110,936.03 101,340.70 5,797.22 3,798.11 0.00 0.00 S42 - Fracture of shoulder and upper arm
Fracture of the upper limb, initial encounter
Injury, Poisoning and
Certain Other
Consequence s of External
Causes
1 1 2 33
Claimant 7 Female 50-59 Subscriber Yes PPO ACTIVE 95,941.57 92,029.36 24,121.13 26,599.06 41,309.17 3,350.04 3,912.21 A41 - Other septicaemia
Septicemia Certain
Infectious and
Parasitic
Diseases
1 10 63 2 186 45XIGDUO XR TAB 5-1000MG
Claimant 8 Male 40-49 Subscriber Yes PPO ACTIVE 89,468.47 73,618.07 22,710.00 37,902.68 13,005.39 0.00 15,850.40 C20 -
Malignant neoplasm of rectum
Gastrointestin al cancers -colorectal
Neoplasms 2 5 11 27 40MOUNJARO INJ 7.5/0.5
Claimant 9 Male 50-59 Subscriber Yes HMO ACTIVE 82,047.70 71,509.72 33,432.05 23,722.89 14,354.78 5,218.18 10,537.98 N20 -
Calculus of kidney and ureter
Calculus of urinary tract
Diseases of the
Genitourinary
System
3 7 11 2 67 50OZEMPIC INJ 8MG/3ML
Claimant 10 Female 50-59 Subscriber YesPPO RETIREE PRE 65 81,446.72 1,934.84 0.00 0.00 1,934.84 0.00 79,511.88 M54 -
Dorsalgia
Spondylopathi es/spondyloart hropathy
(including infective)
Diseases of the
Musculoskelet al System and
Connective
Tissue
15 55ENBREL SRCLK INJ 50MG/ML
Claimant 11 Male 60-64 Subscriber YesHMO RETIREE PRE 65 64,717.63 61,727.34 0.00 14,159.55 47,567.79 4,250.81 2,990.29 C20 -
Malignant neoplasm of rectum
Gastrointestin al cancers -colorectal
Neoplasms 9 1 50 12JARDIANCE TAB 10MG
Claimant 12 Female 50-59 Subscriber YesPPO RETIREE PRE 65 52,449.59 3,584.05 0.00 1,661.85 1,922.20 0.00 48,865.54 H25 - Senile cataract
Cataract and other lens disorders
Diseases of the Eye and
Adnexa
2 18 45ENBREL SRCLK INJ 50MG/ML
Claimant 13 Male <1-19Dependent Child Yes PPO ACTIVE 52,345.32 52,318.72 0.00 49,256.74 3,061.98 4,559.80 26.60 Q66 -
Congenital deformities of feet
Musculoskelet al congenital conditions
Congenital
Malformations
, Deformations and
Chromosomal
Abnormalities
3 2 11 3OSELTAMIVIR SUS 6MG/ML
Claimant 14 Female 40-49 Subscriber Yes PPO ACTIVE 52,129.13 1,210.39 0.00 359.78 850.61 0.00 50,918.74 K80 -
Cholelithiasis
Biliary tract disease
Diseases of the Digestive
System
1 15 22COSENTYX UNO INJ 300/2ML
Query Totals: 14 1,754,648.87 1,400,709.79 708,245.28 436,954.19 255,510.32 35,352.80 353,939.08 18 100 138 10 619 355
(Paid)
(CITY OF EDINBURG 000243483: ALL)
($50,000)
(Oct 2024 - May 2025)
(FACILITY INPATIENT, FACILITY OUTPATIENT, PROFESSIONAL, PHARMACY)
Claimant ID Member
Age/Gender
Band
Member
Relationship
Description
Currently
Enrolled
Indicator
Benefit
Package
Paid Medical Paid IP Paid OP Paid Prof Paid ER Paid Pharmacy
Paid
Primary
Diagnosis
Primary
CCSR Dx
Level 2
Primary
CCSR Dx
Level 1
IP
Admissions
IP Days OP Visits ER Visits Professional
Visits
Prescriptions Primary Drug
Report Totals: 14 1,754,648.87 1,400,709.79 708,245.28 436,954.19 255,510.32 35,352.80 353,939.08 18 100 138 10 619 355
File details come from the government source that posted it. Updated .