HR & Benefits: Health and Dental RFP Template

NOTICE

September 6, 2019 City of Cleveland Healthcare Request for Proposals

If you are receiving the enclosed RFP for the CITY OF CLEVELAND, please visit: http://www.clevelandohio.gov/CityofCleveland/Home/Government/City Agencies/Finance/RFP

You will be directed to the full RFP including census, claims experience and required City forms.

Thank you.

REQUEST FOR PROPOSALS For CITY OF CLEVELAND

CITY OF CLEVELAND 601 Lakeside Avenue Cleveland, Ohio 44114

Release Date: September 6, 2019 RFP Question Submission: September 23, 2019 Response to Questions from Fedeli: September 25, 2019 Proposals Due to The City: October 8, 2019 Plan Effective Date: April 1, 2020

CITY OF CLEVELAND - RFP

TABLE OF CONTENTS

SECTION

I. GENERAL INFORMATION

. Request for Proposal Notice . Proposal Evaluation Criteria . Conditions and Stipulations

II. CITY INFORMATION

. Request for Medical Benefits . Contributions and Plan Information

III. PROPOSAL FORMS

. Quote Criteria Proposed - Summary of Requested Information

IV. QUESTIONNAIRES

. Medical . Performance Guarantees . Prescription . Dental . Vision . Worksite . Life

IV. APPENDICES

. Summary of Benefits – Current Plan(s) . Employee Census . Claim History / Health History Forms . Pharmacy Repricing Report City of Cleveland – RFP Effective Date: April 1, 2020 Page 2

The CITY reserves the right to modify the scope of services at any time before execution of a contract to add, delete, or otherwise amend any item(s), as it deems necessary, in its sole judgment, and in the best interest of the CITY.

SECTION I – GENERAL INFORMATION

Request for Proposal Notice

Proposal Evaluation Criteria

Conditions & Stipulations

City of Cleveland – RFP Effective Date: April 1, 2020 Page 3

REQUEST FOR PROPOSAL NOTICE

Notice is hereby given that the CITY will accept Proposals for the following specified group insurance benefits until: October 8, 2019

Coverage Desired: Medical, Prescription Drugs, Dental, Vision, Life & AD&D, Voluntary Life & AD&D, Dependent Life, Worksite Benefits

All Proposals shall be clearly identified as ‘Insurance Proposal for the CITY OF CLEVELAND’. Copies of your proposal (One (1) original; One (1) duplicate; One (1) electronic, shall be delivered to the CITY no later than October 8, 2019, at the following address:

CITY OF CLEVELAND Attn: Rob Ryan 601 Lakeside Avenue Room 121 Cleveland, Ohio 44114

Proposals will be evaluated, and the successful vendor(s) may be asked to participate in finalist meetings. The CITY reserves the right to reject any or all proposals, waive formalities and to select the vendor and benefit options that best meet the needs of the CITY and its employees.

Bidders are encouraged to include best pricing with their submission as there is no guarantee of a request for price revisions.

Inquiries, clarification, or requests for additional information should be directed in writing to the following CITY contact:

Kim Stika Client Executive The Fedeli Group [email protected]

City of Cleveland – RFP Effective Date: April 1, 2020 Page 4

GENERAL INFORMATION

Name of Account: CITY of CLEVELAND, OHIO 601 Lakeside Avenue Cleveland, OH 44114

Size of Account: Approximately 6,400 participating employees. Approximately 7,200 employees eligible for coverage.

Coverage’s Desired: Medical, Prescription, Dental, Vision, Life/AD&D, Voluntary Life/AD&D, Dependent Life, Worksite Benefits

Current Funding: Self-Insured – Medical/Prescription Drugs (Anthem - $350,000 Specific Deductible) (MMO - $300,000 Specific Deductible)

Fully-Insured: Dental Vision Life Insurance Worksite Benefits

Funding Desired: Self-Insured: Medical Prescription Drug

Fully-Insured: Dental Vision Life Insurance Worksite Benefits

Current Vendor: Medical – Anthem/Medical Mutual

Prescription – CVS Health (Health Action Council)

Dental - CIGNA Vision – EyeMed Life Insurance – MetLife Worksite - Trustmark

Eligibility: First of the month following date of hire City of Cleveland – RFP Effective Date: April 1, 2020 Page 5

GENERAL INFORMATION (continued)

Employee Contribution (per month):

MEDICAL/RX

Medical Mutual $750 Deductible $65.66 Single / $155.12 Family** $83.16 Single / $199.42 Family (Non-Wellness Rate)

Anthem $750 Deductible $83.56 Single / $193.62 Family** $105.84 Single / $248.94 Family (Non-Wellness Rate)

Prescription $15.50 Single / $33.30 Family (CVS)** $19.64 Single / $42.82 Family (CVS - Non-Wellness Rate)

DENTAL

CIGNA Option I - PPO $3.70 Single / $9.48 Family

Option II - DHMO $2.82 Single / $7.22 Family

LIFE & AD&D/Vol LIFE & AD&D

MetLife Please see attached schedules and rates

VISION*

EyeMed $0.84 (EyeMed Composite)

*Please note: AFSCME Local 100 members do not participate in the EyeMed Vision plan

**Rates displayed are the “Wellness” rates and represent a 4% discount off the full employee contribution amounts

City of Cleveland – RFP Effective Date: April 1, 2020 Page 6

GENERAL INFORMATION (continued)

NOTE: School Guards have a separate plan design but may buy-up to either the $750 Deductible Medical Mutual or Anthem plan.

Medical Mutual $1,000 Deductible $10.50 Single / $26.26 Family

Buy up to:

Medical Mutual $750 Deductible $159.29 Single/$267.22 Family

Anthem $750 Deductible $278.64 Single/Family-Not Available

CIGNA (Dental) $5.26 Single/$15.76 Family

MetLife (Life & AD&D/Vol Life & AD&D) Employee pays $2.82 per month For $15,000 Basic Life

Rate Guarantee Period: The CITY will entertain a multi-year administrative fee guarantee or a one-year fee with a subsequent cap. Other options will be considered. The CITY will entertain a multi-year stop loss offer.

Effective Date: April 1, 2020

Commissions: Net of Broker / Consultant Commission

City of Cleveland – RFP Effective Date: April 1, 2020 Page 7

PROPOSAL EVALUATION CRITERIA

The CITY will evaluate and select proposals based on the needs of the CITY and its members. The CITY is not obligated to award the contract based on cost alone.

The following criteria will be used in evaluating each of the responses:

1. Compliance with specifications.

2. Ability to provide administrative support and member services to the CITY and its covered employees and dependents.

3. Compliance with applicable State and Federal laws and regulations.

4. Financial strength of insurance company or managed care organization.

5. Financial rating (if applicable).

6. Retention costs, administration fees and renewal underwriting procedures.

7. Rate guarantees.

8. Completion of the Rate and Benefit Proposal Forms and Questionnaires.

9. Size and location of the Medical Plan Provider Network (or Networks).

10. Nature of medical provider contracts, including discounts and other cost containment methods.

11. Ability to provide the CITY with the reports requested in the proposal.

12. Ability to provide AdHoc reports as requested.

13. Ability to administer claims processing in a seamless and efficient manner.

14. Effectiveness of the drug formulary.

15. Ability to meet the quality of care standards under the National Committee for Quality Assurance (NCQA). Is this still the standard?

16. The ability of the CITY to customize a benefit program that will meet the needs of its employees and labor contracts.

17. Other criteria identified by the CITY as important in evaluation of submitted proposals.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 8

PROPOSAL EVALUATION CRITERIA (continued)

18. The amount of Wellness dollars provided.

19. The amount of clinical data warehouse feed credits offered.

20. Willingness to offset pharmacy data integration fees.

21. Effectiveness of member engagement, onsite wellness resources, and clinical management programs.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 9

CONDITIONS AND STIPULATIONS

You are invited to submit your proposal for the administration of the indicated benefit plans based on the information contained in this Request for Proposal. Unless a specific note is made to the contrary, we will assume that your proposal conforms to the CITY’s specifications.

You are invited to ask questions during the proposal process and to seek additional information, if needed. We want this to be an interactive process and will make every effort to provide sufficient data for your response.

Telephone calls and meeting requests (regarding the RFP) will not be permitted. All correspondence must be submitted in the form of a question and sent to the following dedicated email address: [email protected].

General Conditions and Stipulations

1. Underwriting information pertaining to the CITY is correct and accurate to the best of our knowledge. All vendors submitting proposals will be provided information regarding changes or additions to the underwriting data.

2. The CITY reserves the right to accept or reject any or all proposals and to waive formalities and select the vendor and benefit options that best meet the needs of the CITY and its employees. The CITY’s objective is to select a vendor(s) who will provide the best possible service at the best possible cost while meeting the Request for Proposal specifications. The CITY is not obligated to award the contract based on cost alone.

3. Any proposed deviations to any part of these specifications must be submitted in writing as a part of the proposal, clearly identified in the appropriate section of the proposal. Any deviation deemed to be significant by the CITY will disqualify the proposal.

4. Proposals can be for one or more of the specified group benefits. However, the rate for each benefit must be independently determined. Package offers must be clearly identified including the impact of unbundling offers.

5. Vendor(s) that are awarded the business shall submit properly executed contracts to the CITY within sixty (60) days of the date they are awarded the business.

6. The Vendor(s) awarded the business shall be required to provide the CITY various financial data upon request of the CITY or its consultant.

7. All Vendors must be in full compliance with the State of Ohio and all Federal government requirements relating to the requested coverage or administration of or insuring of such benefits.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 10

CONDITIONS AND STIPULATIONS (continued)

Onboarding and Open Enrollment

Comprehensive benefit summaries must be made available to each covered participant at enrollment. Individual certificates, member cards or other pertinent information must be provided no later than 30 days after the effective date or delivery of enrollment data.

1. A servicing representative must be available to the CITY on an on-going basis. Representatives must be available at the initial open enrollment meetings to explain the plan and available programs.

2. All vendors providing coverage through Medical, Rx, Dental, Vision, Life and/or Worksite benefits must share in the cost of open enrollment materials including:

a. Cost of printing annual Benefit Guides b. Cost of mailing Benefit Guides to all eligible employees

Coverage Conditions and Stipulations

1. Coverage under the accepted plan shall become effective on April 1, 2020. The vendor has the right to amend rates at the beginning of the next plan period.

2. Multiple year fees and/or rate guarantees are encouraged.

3. Deductibles and out-of-pocket expenses already paid by a participant during the existing year should be honored if there are any mid-year changes in vendors and/or plans. Deductibles and out-of- pocket expenses should be honored for the prior three (3) months when there is a new vendor and/or plan selected at the beginning of a new contract year.

Eligibility and Enrollment Conditions and Stipulations

1. Enrolled participants shall be immediately eligible for the plan upon its effective date. Any employee absent from work due to illness or injury on the date coverage would otherwise become effective shall, upon return to work, have coverage retroactive to the effective date.

2. Employees eligible to participate in the plan are permanent employees whose usual work schedule is an average of 30 hours per week.

3. A spouse, eligible dependents include unmarried natural children, stepchildren, legally adopted children, permanent foster children, or any other child who is related to the eligible employee by blood or marriage. Employees may be required to submit evidence of insurability for themselves and dependents, as applicable.

4. The CITY reserves the right to administer a grace period for initial enrollment as it deems necessary for extenuating circumstances. City of Cleveland – RFP Effective Date: April 1, 2020 Page 11

SECTION II – CITY INFORMATION

Request for Medical and Prescription Drug Benefits

City of Cleveland – RFP Effective Date: April 1, 2020 Page 12

REQUEST FOR MEDICAL AND PRESCRIPTION DRUG BENEFITS

Funding Requested: Self-Insured

The CITY currently offers its employees major medical options through Anthem and Medical Mutual of Ohio. It is the intent of the CITY to continue offering the same medical plan through either one insurance vendor or a combination of two. Bidders must clearly indicate pricing and any differences between plans.

The CITY requests all quoting vendors match the current medical plans provided. Ratification of new plans will be provided to the vendor(s) as soon as available and employees will receive a notice of change at least 60 days prior to the benefit change if off renewal.

CONTRIBUTIONS AND PLAN INFORMATION

Medical Premium Contribution

The employees currently contribute 15% for single coverage and 14% for family coverage with participation in the wellness program. The non-wellness contribution is 19% for single coverage and 18% for family coverage.

Premium and Claims History

See premium / claim report included.

Clinical Cost Drivers

See clinical report for chronic condition ranking.

Employee Census

See employee census report included in the attachments.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 13

PARTICIPANT BREAKDOWN

Average number of contracts: July 2018 – June 2019

SINGLE FAMILY TOTAL

Medical Mutual 1687 2729 4416

Anthem 811 1431 2242

City of Cleveland – RFP Effective Date: April 1, 2020 Page 14

SECTION III – PROPOSAL FORMS

Quote Criteria - Proposed

Medical/Rx

Specific Contract Aggregate Funding Coverage Claim Threshold Deductibles Basis Corridor Medical/Rx $300,000 Self- under the Coverage should begin as the $350,000 12/18 120% Insured Specific and threshold is met. $400,000 Aggregate Note: Medical and Prescription Drug plan designs should remain the same as negotiated in the contracts.

General Information • All rates should be quoted on a Single / Family basis. • Indicate the amount of wellness dollars you will provide for the CITY annually. • Please indicate if unused wellness funds rollover. • Multi-year quotes are strongly encouraged.

Dental and Vision

Dental Plans Vision Plans Funding PPO and DHMO matching PPO matching current Fully insured dental and vision current

Life Insurance

Please match the current life benefit for all full-time eligible employees.

Worksite Programs The four current and requested voluntary programs are: 1. Voluntary Short-Term Disability Coverage a. 7 day waiting period; 3 month/90 day waiting period b. 14 day waiting period; 3 month/90 day waiting period c. 14 day waiting period; 6 month/180 day waiting period 2. Voluntary Critical Illness Coverage 3. Voluntary Permanent Life Insurance Coverage with Long-Term Care Benefits 4. Accident City of Cleveland – RFP Effective Date: April 1, 2020 Page 15

SECTION IV – QUESTIONNAIRES (Medical, Prescription, Dental, Vision, Life and Worksite)

Note: A complete response to all questionnaires must accompany proposed benefits. A response such as “See Proposal” is not sufficient unless there is a proper reference to the specific section of the proposal addressing the questions. Please be specific in your answers.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 16

Medical Questionnaire

1. Confirm that your proposal is for a “full service” arrangement where your company provides its standard services and list of services that you consider standard.

2. Identify where standard services differ by plan.

3. Provide the name, address, phone number, years of experience with your organization of the person(s) in charge or responsible for the following key roles on the CITY account.

a. Group Sales and Service and Claims Administration b. Account Manager and any or all Assistants c. Eligibility Specialist d. Billing Specialist e. Implementation Coordinator f. Day-to-Day Liaison with The Fedeli Group and the CITY g. Wellness Coordinator

4. Provide three public sector customer references for groups similar in size to the CITY. Provide the following information for each reference:

a. Customer name b. Individual contact name and title c. Address d. Phone number e. Coverage(s) with your company f. Number of years as a client

5. Account management is extremely important to the CITY. The CITY has the following expectations about account management and customer service aspects:

a. The account manager would be available for weekly (or as needed) meetings during the implementation period leading up to April 1, 2020 effective date. b. The account manager would maintain regular (at least monthly) contact with The Fedeli Group as well as the CITY to resolve ongoing issues as needed.

6. Describe your premium and administrative billing system. Be sure to explain how mid- month additions and terminations are handled with respect to back adjustments or credits.

7. Submit a copy of your standard premium or administrative statement.

8. Submit a copy of your standard utilization reporting package.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 17

Medical Questionnaire (continued)

9. Submit a copy of your standard Plan Document and summary plan description (SPD)/booklet/ certificate of insurance/marketing/marketing materials.

a. Please confirm that you will administer the Plan(s) as described in the Plan Document and that the Plan Document is the responsibility of the Plan Sponsor.

b. Please confirm that you are or are not a Plan Fiduciary. If deemed a Plan Fiduciary that you accept all liability associated with being a fiduciary.

10. Provide an outline of all participation and other relevant assumptions you have made in your rate quotations.

11. Do you require a minimum level of participation for any of the plans or locations? How flexible are these requirements?

12. Claims and administration expense via ACH or Wire transfer?

13. Do you offer multi-year rate guarantees? If so, describe your offer.

14. Please include a copy of your most recent annual report.

15. Describe your organization’s current financial ratings from the major financial rating agencies listed below. Have any of these ratings changed in the last 12 months? If so, what was the former rating and why did it change?

a. A.M. Best b. Standard & Poor’s c. Moody’s d. Duff & Phelps

16. Has your plan been reviewed by the NCQA? If yes, what is your accreditation status (i.e., full three years, provisional, denied, or under review). If no, describe your intentions to become accredited. Is an initial review pending or scheduled? If your plan has been denied accreditation, please explain the reason for denial and the steps you have taken or will take to correct any deficiencies causing the denial.

17. Have you received any recommendations from NCQA? If yes, please list the recommendations and the status of actions being taken/already taken to address and/or resolve the recommendation.

18. Describe your narrow network or ACO.

19. Describe any clinically integrated networks that you offer.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 18

Medical Questionnaire (continued)

20. Will you provide a population health guarantee to demonstrate the effectiveness of:

a. Care Management b. Network efficiency c. Utilization Management d. Other clinical programs

21. Please describe any innovative employee engagement, advocacy, or population health programs being offered.

22. Please confirm your agreement to allow independent third-party claim audits to be conducted at the CITY’s expense and your willingness to accept their reported findings for purposes of performance guarantee goal measurement.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 19

PERFORMANCE GUARANTEES

Please confirm your ability to commit to the following:

Claim Turnaround Time

1. Standard a. 95% of all claims processed in 30 calendar days 2. Definition a. Claim turnaround time is calculated from the date the claim is received in the PAYOR’s office to the date it was processed. Adjusted claims are included in this calculation. Claim turnaround time will be measured and reported on a monthly basis for CITY claims only. 3. Please provide your Administrative fee you are willing to put at risk

Financial Accuracy

1. Standard a. 99% accuracy 2. Definition a. The financial accuracy of a universe of claims is the total dollars paid correctly divided by the total dollars paid, stated as a percentage. A statistically valid sample of the CITY claims processed each month will be measured and reported on a monthly basis for the CITY claims only. 3. Please provide your Administrative fee you are willing to put at risk in addition to claim payment correction.

Processing Accuracy

1. Standard a. 97% accuracy 2. Definition a. The processing accuracy of a universe of claims is the number of claims processed correctly divided by the number of claims audited. A statistically valid sample of the CITY claims processed each month will be measured and reported on a monthly basis for the CITY claims only.

b. All payments made on behalf of the plan to eligible plan participants and Vendors, for approved services, shall be in accordance with the Plan Document and policies of CITY the PAYOR shall identify claims that have been incorrectly processed, and initiate appropriate action to correct processing outcomes. The PAYOR shall notify the CITY, by letter, of any system errors that result in a potential Vendor or plan participant overpayment or other incorrect payment and describe in detail the plan and deadlines for corrective action. City of Cleveland – RFP Effective Date: April 1, 2020 Page 20

PERFORMANCE GUARANTEES (continued)

Processing Accuracy (continued)

Please provide your Administrative fee you are willing to put at risk in addition to claim payment correction.

3. The PAYOR shall provide CITY with a monthly report of all overpayments, duplicate payments, and payments to the wrong payee reflecting the status of corrections, adjustments, and collections resulting from errors.

Overpayments

1. What is the threshold for overpayment recovery not associated with subrogation? 2. Does your firm use outside vendors for overpayment recovery not associated with subrogation? 3. What percentage is retained for overpayments not associated with subrogation?

Telephone Call Answer Time

1. Standard a. 95% Answered within 30 seconds 2. Definition a. Telephone call answer time measures “live” calls only. CITY call activity will be measured and reported on a monthly basis for the Client only. 3. Please provide your Administrative fee you are willing to put at risk

Telephone Drop/Abandonment Rate

1. Standard a. Less than 3% 2. Definition a. An abandoned call is defined as an individual hanging up once in the que. CITY call activity will be measured and reported on a monthly basis for the Client only. 3. Please provide your Administrative fee you are willing to put at risk.

Claim Process

1. What is the name and description of the code editing software used? 2. Have all available CMS NCCI edits been incorporated into your coded editing software through customization? 3. If not, are you willing to incorporate all CMS NCCI edits into your software for the CITY within six months of implementation? City of Cleveland – RFP Effective Date: April 1, 2020 Page 21

Prescription Questionnaire

The CITY, through CVS Caremark and the Health Action Council, carves out the prescription drug coverage. In an effort to continue carving out the prescription drugs, your confirmation is needed to the following:

1. Provide most recent 6 months historical claims file. 2. Confirm there will be no cost to setup accumulator or any other type of file feeds. 3. Please describe your fees for pharmacy benefit management. 4. Describe all programs built into the drug plan. 5. Please include price for all optional programs. 6. Describe your formulary rebate offer. 7. Is there a specialty rebate guarantee? 8. Please describe pricing improvements that may benefit the CITY. 9. Please provide your current formulary. What is the basis of your formulary? Rebates, efficacy, etc.? 10. Please provide a pricing based on your contracts and illustrating average wholesale price discount, MAC, and average rebates for both retail and home delivery. You may illustrate in any format recognizable however, you will be asked to guarantee contracts. 11. Do you provide full transparency? 12. Do you provide for 90 day fills at retail with a higher AWP discount? If so, what is the AWP? 13. Please provide the protocols for step therapy. 14. Is the pharmacy eligibility in real time? If not, what is the batch timing? 15. How often do you change formulary? 16. Is the home delivery program monitoring and ordering available on-line? 17. Please provide pricing based on baseline AWP models as well as full transparent models. 18. Do you block repackaged NDCs’? Brand and generic? 19. Please provide a list of all drug rebates attained and rebate types (market-share administration, clinical, etc.). 20. Do coupons effect deductibles and copays? 21. How do you integrate the disease management and pharmaceutical compliance component, whether integrated or in a carve-out PBM.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 22

Dental Questionnaire

1. Please list five of your largest public sector clients and, to the extent possible, clients who are located in Ohio. 2. Please provide a Disruption analysis for the PPO and DHMO plans. 3. Please provide the average provider discounts of Usual, Customary and Reasonable (UCR) for a general dentist and a dental specialist. 4. If a Provider drops/leaves your network, how are enrollees notified? 5. Provide the transition of care benefits for the dental PPO and dental HMO plans separately, and address treatment in progress, orthodontia and other treatments. 6. Please provide your performance standards including the targets and actual results for the most recent period for financial, processing and payment accuracy for your book-of-business. 7. What is your referral process for the dental HMO plan? Please provide average time for referrals. 8. List any additional services you will be providing under your fully insured dental plan which were not requested in this RFP.

Vision Questionnaire

1. Please provide a Disruption analysis for the Vision plan. 2. Does your vision plan provide ID cards to all members at no cost? a. Are ID cards accessible via the mobile application? 3. Describe additional discounts offered to members. 4. Do providers have a choice of labs? Please describe your lab network. 5. Describe your process for member appeals. 6. Describe your reporting capabilities and frequencies. a. Please include any additional fees associated with reporting. 7. Outline specific performance guarantees that you are willing to offer.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 23

Worksite Benefits Questionnaire

1. The CITY requires that only products approved by the CITY can be sold to participants. Please confirm.

2. Please explain the insurance programs you are proposing for the CITY OF CLEVELAND

3. Please see additional information and questions regarding the current voluntary programs at the end of this Request for Proposal, and also include:

a. Schedule of Monthly Rates b. Complete Description of Benefits c. Complete Description of All Limitations & Exclusions d. Specimen Policy for Each Plan

4. Are you subcontracting? Provide details.

5. How long has your company provided voluntary benefits?

6. Please provide sample employee communication services provided for voluntary benefits and explain your resources to support customized communications.

7. Describe your company’s reimbursement process.

8. Describe your company’s claims submission requirements.

9. Specify your company’s payment processing time between claims submission and policyholder reimbursement.

10. How will CITY employees access your company’s customer service?

11. Do you provide a toll-free number for employee’s telephonic inquiries?

12. Describe how you will accommodate the CITY workforce. Our employees work 24 hours a day, 7 days a week.

13. The CITY will continue onsite counseling services supported via a call center through a third- party firm. The CITY expects to incorporate enrollment on to the ADP enrollment platform. Please confirm you understand the enrollment methodology.

14. What additional employee services will your firm provide for CITY staff members?

15. Provide a time line for implementation.

16. The Voluntary Benefits program vendor must mail to participants’ homes any required W-2 or 1099 forms. Please confirm.

17. Will you be able to work with ADP as the CITY’s payroll vendor?

City of Cleveland – RFP Effective Date: April 1, 2020 Page 24

Life Insurance Questionnaire

1. Provide a description of documents needed in order for claims to be filed.

2. Describe how claims are processed and timeline for claim payment.

3. Please describe your procedure for notifying members of approval or denial of voluntary life/AD&D coverage applied for in excess of the guaranteed issue limit.

4. Please describe your Evidence of Insurability procedure.

5. Please provide three client references (preferably public entities) of a similar size.

6. Is your company currently involved in any litigation as a defendant over any life insurance benefit?

7. Will your company provide on-site enrollment assistance?

8. Will your company provide an ongoing annual open enrollment including GI?

9. Indicate the ratings given to your company by the following:

a. AM Best

b. Standard & Poor’s

c. Moody’s

d. Fitch

9a. Has there been any change in your ratings in the last 2 years? If yes, please explain.

10. Are there any pending agreements to merge or sell your company?

11. Within the last five years, has your firm ever defaulted on a contract to provide a group life insurance plan? Has your firm been involved in litigation regarding such contracts?

12. Please provide three current client references, preferably public sector clients of the same size.

13. Identify key staff members who would have day-to-day contact with the City’s Human Resources staff. Identify their duties and their experience working with public sector clients.

14. Are you willing to pay a portion of the cost of printing annual open enrollment benefit guides for employees? This will be billed from The Fedeli Group.

15. Describe a value-added services or products you offer.

City of Cleveland – RFP Effective Date: April 1, 2020 Page 25

APPENDICES

City of Cleveland – RFP Effective Date: April 1, 2020 Page 26

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 04/01/2019 - 03/31/2020 City of Cleveland Employees : Plan 2 Coverage for: Single or Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 800-540-2583. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at MedMutual.com/SBC or call 800-540-2583 to request a copy.

Important Questions Answers Why This Matters:

What is the overall $750/single,$1,500/family Network Generally, you must pay all of the costs from providers up to the deductible amount before this plan deductible? $750/single,$1,500/family Non-Network begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered Yes. Certain preventive care and all This plan covers some items and services even if you haven’t yet met the deductible amount. But a before you meet your services with copayments are copayment or coinsurance may apply. For example, this plan covers certain preventive services deductible? covered and paid by the plan before without cost-sharing and before you meet your deductible. See a list of covered preventive you meet your deductible. services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other deductibles No You don’t have to meet deductibles for specific services. for specific services? What is the out-of-pocket limit $2,250/single,$4,500/family Network The out-of-pocket limit is the most you could pay in a year for covered services. If you have other for this plan? $5,750/single,$11,500/family family members in this plan, they have to meet their own out-of-pocket limits until the overall family Non-Network out-of-pocket limit has been met. Cost sharing for prescription drugs, What is not included in the Even though you pay these expenses, they don't count toward the out-of-pocket limit. premiums, balance-billed charges and out-of-pocket limit? health care this plan doesn't cover. Will you pay less if you use a Yes, See MedMutual.com/SBC or call This plan uses a provider network. You will pay less if you use a provider in the plan's network. network provider? 800-540-2583 for a list of participating You will pay the most if you use an out-of-network provider, and you might receive a bill from a providers. provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a No You can see the specialist you choose without a referral. specialist?

Page 1 of 5 228383325 BEN1905191365101-00002 All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Services with copayments are covered before you meet your deductible, unless otherwise specified.

Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider Non-Network Provider (You will pay the least) (You will pay the most) If you visit a health care Primary care visit to treat an injury or $20 copay/visit 30% coinsurance None provider's office or clinic illness Specialist visit $30 copay/visit 30% coinsurance None Preventive care/ screening/ No charge 30% coinsurance You may have to pay for services immunization that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. If you need drugs to treat your Prescription Drug Coverage Not Covered by Medical Not Covered Excluded Service illness or condition Carrier

If you have outpatient surgery Facility fee (e.g., ambulatory surgery 10% coinsurance 30% coinsurance None center) Physician/surgeon fees (Outpatient) 10% coinsurance 30% coinsurance None If you need immediate medical Emergency room care $100 copay/visit None attention Emergency medical transportation 10% coinsurance 30% coinsurance None Urgent care $20 copay/visit 30% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance None Physician/ surgeon fee (inpatient) 10% coinsurance 30% coinsurance None If you need mental health, Outpatient services Benefits paid based on corresponding medical benefits None behavioral health, or Inpatient services Benefits paid based on corresponding medical benefits None substance abuse services

Page 2 of 5 228383325 BEN1905191365101-00002 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider Non-Network Provider (You will pay the least) (You will pay the most) If you are pregnant Office visits No charge 30% coinsurance Cost sharing does not apply to certain preventive services. Depending on the type of services, copay, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional 10% coinsurance 30% coinsurance None services Childbirth/delivery facility services 10% coinsurance 30% coinsurance None If you need help recovering or Home health care 10% coinsurance 30% coinsurance None have other special health Rehabilitation services (Physical 10% coinsurance 30% coinsurance (10 visits, then Medical Review - needs Therapy) Professional; unlimited - Institutional; combined with Occupational Therapy and Chiropractic) Habilitation services (Occupational 10% coinsurance 30% coinsurance (10 visits, then Medical Review - Therapy) Professional; unlimited - Institutional; combined with Physical Therapy and Chiropractic) Habilitation services (Speech 10% coinsurance 30% coinsurance (10 visits, then Medical Review - Therapy) Professional; unlimited - Institutional) Skilled nursing care 10% coinsurance 30% coinsurance None Durable medical equipment 10% coinsurance 30% coinsurance None Hospice services 10% coinsurance 30% coinsurance None If your child needs dental or Children's eye exam No charge 30% coinsurance None eye care Children's glasses Not Covered Excluded Service Children's dental check-up Not Covered Excluded Service

Page 3 of 5 228383325 BEN1905191365101-00002 Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Dental Care (Adult) • Non-emergency care when traveling outside the U.S. • Children's dental check-up • Hearing Aids • Routine Eye Care (Adult) • Children's glasses • Infertility Treatment • Routine Foot Care • Cosmetic Surgery • Long-Term Care • Weight Loss Programs

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) • Bariatric Surgery • Chiropractic Care • Private-Duty Nursing

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends.The contact information for those agencies is: the Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 877-267-2323 x61565 or cciio.cms.gov. Other coverage options may be available to you, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call 800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact your plan at 800-540-2583. Does this plan provide Minimum Essential Coverage? Yes. If you don't have Minimum Essential Coverage for a month, you'll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet Minimum Value Standards? Yes. If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

------To see examples of how this plan might cover costs for sample medical situations, see the next section------The coverage example numbers assume that the patient does not use an HRA or FSA. If you participate in an HRA or FSA and use it to pay for out-of-pocket expenses, then your costs may be lower.

Page 4 of 5 228383325 BEN1905191365101-00002 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is having a baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a (in-network emergency room visit and follow up hospital delivery) well-controlled condition) care) n The plan's overall deductible $750 n The plan's overall deductible $750 n The plan's overall deductible $750 n Specialist copay $30 n Specialist copay $30 n Specialist copay $30 n Hospital (facility) coinsurance 10% n Hospital (facility) coinsurance 10% n Hospital (facility) coinsurance 10% n Other coinsurance 10% n Other coinsurance 10% n Other coinsurance 10%

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like: Specialist office visits (prenatal care) Primary care physician office visits (including disease Emergency room care (including medical supplies) Childbirth/Delivery Professional Services education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $750 Deductibles $0 Deductibles $750 Copayments $0 Copayments $100 Copayments $200 Coinsurance $1,100 Coinsurance $0 Coinsurance $30 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $1,100 Limits or exclusions $6,200 Limits or exclusions $60 The total Peg would pay is $2,950 The total Joe would pay is $6,300 The total Mia would pay is $1,040 Note: These numbers assume the patient does not participate in the plan's wellness program. If you participate in the plan's wellness program, you may be able to reduce your costs. For more information about the wellness program, please contact: 800-540-2583.

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 5 of 5 228383325 BEN1905191365101-00002 Multi-Language Interpreter Services & Nondiscrimination Notice

This document notifies individuals of how to seek assistance if they speak a language other than English.

Spanish Oromo ATENCIÓN: Si habla español, tiene a su disposición XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, servicios gratuitos de asistencia lingüística. Llame al tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni 1-800-382-5729 (TTY: 711). argama. Bilbilaa 1-800-382-5729 (TTY: 711).

Chinese Korean 注意:如果您使用繁體中文,您可以免費獲得語言援助服 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 務。請致電 1-800-382-5729 (TTY: 711)。 무료로 이용하실 수 있습니다. 1-800-382-5729 (TTY: 711)번으로 전화해 주십시오. German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Italian Ihnen kostenlos sprachliche Hilfsdienstleistungen zur ATTENZIONE: In caso la lingua parlata sia l’italiano, Verfügung. Rufnummer: 1-800-382-5729 (TTY: 711). sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-382-5729 (TTY: 711). Arabic Japanese ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغویة تتوافر لك 注意事項:日本語を話される場合、無料の言語支援を ( بالمجان. اتصل برقم 5729-382-800-1 رقم ھاتف الصم والبكم 711). ご利用いただけます。1-800-382-5729 (TTY: 711) ま Pennsylvania Dutch で、お電話にてご連絡ください。 Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf Dutch selli Nummer uff: Call 1-800-382-5729 (TTY: 711). AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel Russian 1-800-382-5729 (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Ukrainian Звоните 1-800-382-5729 (телетайп: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної French підтримки. Телефонуйте за номером 1-800-382-5729 ATTENTION: Si vous parlez français, des services (телетайп: 711). d’aide linguistique vous sont proposés gratuitement. Appelez le 1-800-382-5729 (ATS: 711). Romanian ATENT, IE: Dacă vorbit,i limba română, vă stau la Vietnamese dispozit,ie servicii de asistent,ă lingvistică, gratuit. CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ Sunat,i la 1-800-382-5729 (TTY: 711). miễn phí dành cho bạn. Gọi số 1-800-382-5729 (TTY: 711). Tagalog Navajo PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari Díí baa akó nínízin: Díí saad bee yáníłti’ go Diné kang gumamit ng mga serbisyo ng tulong sa wika nang Bizaad, saad bee áká’ánída’áwo’dę΄ę΄’, t’áá jiik’eh, éí walang bayad. Tumawag sa 1-800-382-5729 (TTY: 711). ná hólǫ´, kojį’ hódíílnih 1-800-382-5729 (TTY: 711).

Z8188-MCA R11/16 QUESTIONS ABOUT YOUR BENEFITS OR OTHER INQUIRIES ABOUT YOUR HEALTH INSURANCE SHOULD BE DIRECTED TO MEDICAL MUTUAL’S CUSTOMER CARE DEPARTMENT AT 1-800-382-5729.

Nondiscrimination Notice

Medical Mutual of Ohio complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex in its operation of health programs and activities. Medical Mutual does not exclude people or treat them differently because of race, color, national origin, age, disability or sex in its operation of health programs and activities. n Medical Mutual provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, etc.). n Medical Mutual provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services or if you believe Medical Mutual failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, with respect to your health care benefits or services, you can submit a written complaint to the person listed below. Please include as much detail as possible in your written complaint to allow us to effectively research and respond.

Civil Rights Coordinator Medical Mutual of Ohio 2060 East Ninth Street Cleveland, OH 44115-1355 MZ: 01-10-1900 Email: [email protected]

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. n Electronically through the Office for Civil Rights Complaint Portal available at: ocrportal.hhs.gov/ocr/portal/lobby.jsf n By mail at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington, DC 20201-0004 n By phone at: (800) 368-1019 (TDD: (800) 537-7697) n Complaint forms are available at: hhs.gov/ocr/office/file/index.html

Products marketed by Medical Mutual may be underwritten by one of its subsidiaries, such as Medical Health Insuring Corporation of Ohio or Consumers Life Insurance Company.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 04/01/2019 - 03/31/2020 City Of Cleveland: Anthem Blue Access PPO – Ratified Non-Union Coverage for: Individual + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/aso. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (833) 639-1634 to request a copy.

Important Questions Answers Why This Matters: What is the overall $750/person or $1,500/family Generally, you must pay all of the costs from providers up to the deductible amount before deductible? for Network Providers. this plan begins to pay. If you have other family members on the plan, each family member $750/person or $1,500/family must meet their own individual deductible until the total amount of deductible expenses paid for Non-Network Providers. by all family members meets the overall family deductible.

Are there services Yes. Primary Care Specialist This plan covers some items and services even if you haven’t yet met the deductible amount. covered before you Visit Preventive Care for But a copayment or coinsurance may apply. For example, this plan covers certain preventive meet your deductible? Network Providers. services without cost-sharing and before you meet your deductible. See a list of covered preventive services at https://www.healthcare.gov/coverage/preventive-care-benefits/. Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of- $2,250/person or $4,500/family The out-of-pocket limit is the most you could pay in a year for covered services. If you have pocket limit for this for Network Providers. other family members in this plan, they have to meet their own out-of-pocket limits until the plan? $5,750/person or overall family out-of-pocket limit has been met. $11,500/family for Non- Network Providers. What is not included Premiums, balance-billing Even though you pay these expenses, they don’t count toward the out-of-pocket limit. in the out-of-pocket charges, and health care this limit? plan doesn't cover. Will you pay less if Yes, Blue Access. See This plan uses a provider network. You will pay less if you use a provider in the plan’s you use a network www.anthem.com or call (833) network. You will pay the most if you use an out-of-network provider, and you might receive provider? 639-1634 for a list of network a bill from a provider for the difference between the provider’s charge and what your plan providers. pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

OH/LG/City Of Cleveland: Anthem Blue Access PPO/44VU/04-19 1 of 10

Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist?

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Common Services You May Need Tier 1 Network Provider Non-Network Provider Limitations, Exceptions, & Medical Event (You will pay least) (You will pay the most) Other Important Information Primary care visit to treat an $20/visit deductible does not 30% coinsurance ------none------injury or illness apply $30/visit deductible does not Specialist visit 30% coinsurance ------none------If you visit a apply health care You may have to pay for services provider’s office that aren't preventive. Ask your or clinic Preventive care/ screening/ No charge 30% coinsurance provider if the services needed immunization are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood No charge 30% coinsurance Costs may vary by site of service. If you have a test work) Imaging (CT/PET scans, MRIs) 10% coinsurance 30% coinsurance Costs may vary by site of service. If you need drugs Tier 1 - Typically Generic Not covered Not covered to treat your Tier 2 - Typically Preferred illness or Brand & Non-Preferred Not covered Not covered condition Generic Drugs More information Tier 3 - Typically Non-Preferred Not covered Not covered Carved out to Caremark about prescription Brand and Generic drugs drug coverage is available at Tier 4 - Typically Preferred Not covered Not covered Specialty (brand and generic) www.[insert]. Facility fee (e.g., ambulatory If you have 10% coinsurance 30% coinsurance ------none------outpatient surgery center) surgery Physician/surgeon fees 10% coinsurance 30% coinsurance ------none------$100/visit deductible does not Emergency room care Covered as In-Network Copay waived if admitted. apply Non-emergency non-network If you need Emergency medical 10% coinsurance Covered as In-Network Ambulance Services are limited immediate transportation medical attention to $50,000/trip. $20/visit deductible does not Urgent care 30% coinsurance ------none------apply

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 2 of 10

What You Will Pay Common Services You May Need Tier 1 Network Provider Non-Network Provider Limitations, Exceptions, & Medical Event (You will pay least) (You will pay the most) Other Important Information 60 days/benefit period for Inpatient physical medicine, rehabilitation including day Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance If you have a rehabilitation programs Tier 2 hospital stay Network and Non-Network Providers combined. Physician/surgeon fees 10% coinsurance 30% coinsurance ------none------Office Visit Office Visit Office Visit If you need $20/visit deductible does not 30% coinsurance ------none------mental health, Outpatient services apply Other Outpatient Other Outpatient behavioral health, Other Outpatient or substance 30% coinsurance ------none------10% coinsurance abuse services Inpatient services 10% coinsurance 30% coinsurance ------none------$20/visit deductible does not Office visits 30% coinsurance apply Maternity care may include tests Childbirth/delivery professional If you are 10% coinsurance 30% coinsurance and services described elsewhere services pregnant in the SBC (i.e. ultrasound). Childbirth/delivery facility 10% coinsurance 30% coinsurance services Home health care 10% coinsurance 30% coinsurance ------none------$30/visit deductible does not Rehabilitation services 30% coinsurance apply If you need help *See Therapy Services section recovering or $30/visit deductible does not Habilitation services 30% coinsurance have other apply special health Skilled nursing care 10% coinsurance 30% coinsurance ------none------needs *See Durable Medical Durable medical equipment 10% coinsurance 30% coinsurance Equipment Section Hospice services No charge No charge ------none------$30/visit deductible does not If your child Children’s eye exam Not covered apply ------none------needs dental or Children’s glasses Not covered Not covered eye care Children’s dental check-up Not covered Not covered ------none------

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 3 of 10

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) • Acupuncture • Bariatric Surgery • Cosmetic surgery • Dental care (Adult) • Dental care (Pediatric) • Dental Check-up • Eye exams for a child • Glasses for a child • Hearing aids • Infertility treatment • Long-term care • Routine eye care (Adult) • Routine foot care • Weight loss programs

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care 20 visits/benefit period • Most coverage provided outside the • Private-duty nursing 82 visits/benefit United States. See period in a Home Setting only www.bcbsglobalcore.com

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform, or contact Anthem at the number on the back of your ID card. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596.

ATTN: Grievances and Appeals, P.O. Box 105568, Atlanta GA 30348-5568

Department of Labor, Employee Benefits Security Administration, (866) 444-EBSA (3272), www.dol.gov/ebsa/healthreform

Does this plan provide Minimum Essential Coverage? Yes/No If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes/No If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso. 4 of 10 About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only

coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow hospital delivery) controlled condition) up care)

 The plan’s overall deductible $750  The plan’s overall deductible $750  The plan’s overall deductible $750  Specialist copayment $30  Specialist copayment $30  Specialist copayment $30  Hospital (facility) coinsurance 10%  Hospital (facility) coinsurance 10%  Hospital (facility) coinsurance 10%  Other coinsurance 0%  Other coinsurance 0%  Other coinsurance 0%

This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services like: like: like: Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies) Childbirth/Delivery Professional Services disease education) Diagnostic test (x-ray) Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches) Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy) Specialist visit (anesthesia) Durable medical equipment (glucose meter)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900

The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of "

Language Access Services:

(TTY/TDD: 711)

Albanian (Shqip): Nëse keni pyetje në lidhje me këtë dokument, keni të drejtë të merrni falas ndihmë dhe informacion në gjuhën tuaj. Për të kontaktuar me një përkthyes, telefononi (833) 639-1634

Amharic (µ ; M∞ )─ U( Ê & P•ł ; ™∞ € = ěˉd ¿(‹ é x K U‹ i ™i ∫ Mˇ å ∫® ˙ &™ 8 H¹ x•ť ı; Ş≠é 8}é µ( ‹ é ⌂ µ U â MČ : ( ; ®¾M (833) 639-1634 ˙¸€ )⌂

. (833) 639-1634

Armenian (հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք անվճար ստանալ օգնություն և տեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար զանգահարեք հետևյալ հեռախոսահամարով՝ (833) 639-1634:

(833) 639-1634.

(833) 639-1634

Chinese (中文)：如果您對本文件有任何疑問，您有權使用您的語言免費獲得協助和資訊。如需與譯員通話，請致電(833) 639-1634。

(833) 639-1634.

Dutch (Nederlands): Bij vragen over dit document hebt u recht op hulp en informatie in uw taal zonder bijkomende kosten. Als u een tolk wilt spreken, belt u (833) 639-1634.

(833) 639-1634

French (Français) : Si vous avez des questions sur ce document, vous avez la possibilité d’accéder gratuitement à ces informations et à une aide dans votre langue. Pour parler à un interprète, appelez le (833) 639-1634.

6 of "

Language Access Services:

German (Deutsch): Wenn Sie Fragen zu diesem Dokument haben, haben Sie Anspruch auf kostenfreie Hilfe und Information in Ihrer Sprache. Um mit einem Dolmetscher zu sprechen, bitte wählen Sie (833) 639-1634.

Greek (Ελληνικά) Αν έχετε τυχόν απορίες σχετικά με το παρόν έγγραφο, έχετε το δικαίωμα να λάβετε βοήθεια και πληροφορίες στη γλώσσα σας δωρεάν. Για να μιλήσετε με κάποιον διερμηνέα, τηλεφωνήστε στο (833) 639-1634.

Gujarati (χh{Üpàâ ): hë U r Ĥ p Ü~ éh Ốc éU ut éa ëWu o �Ňë É ëz pë, a ëWu o bf ‹~c { U ut à x ÜÅ Üy ÜR yrr Tt éyÜ¶Épà yé}~~Ütë pyt é T á s a Ü{ gé. Ј âx Üá Å z Ü Ç Üq é ~ Üp a{~Ü y Ük œ, a ë| a{ë (833) 639-1634.

Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele (833) 639-1634.

(833) 639-1634

Hmong (White Hmong): Yog tias koj muaj lus nug dab tsi ntsig txog daim ntawv no, koj muaj cai tau txais kev pab thiab lus qhia hais ua koj hom lus yam tsim xam tus nqi. Txhawm rau tham nrog tus neeg txhais lus, hu xov tooj rau (833) 639-1634.

Igbo (Igbo): Ọ bụr ụ na ị nwere ajụjụ ọ bụla gbasara akwụkwọ a, ị nwere ikike ịnweta enyemaka na ozi n'asụsụ gị na akwụghị ụgwọ ọ bụla. Ka gị na ọkọwa okwu kwuo okwu, kpọọ (833) 639-1634.

Ilokano (Ilokano): Nu addaan ka iti aniaman a saludsod panggep iti daytoy a dokumento, adda karbengam a makaala ti tulong ken impormasyon babaen ti lenguahem nga awan ti bayad na. Tapno makatungtong ti maysa nga tagipatarus, awagan ti (833) 639-1634.

Indonesian (Bahasa Indonesia): Jika Anda memiliki pertanyaan mengenai dokumen ini, Anda memiliki hak untuk mendapatkan bantuan dan informasi dalam bahasa Anda tanpa biaya. Untuk berbicara dengan interpreter kami, hubungi (833) 639-1634.

Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero (833) 639-1634

(833) 639-1634

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Language Access Services:

(833) 639-1634

Kirundi (Kirundi): Ugize ikibazo ico arico cose kuri iyi nyandiko, ufise uburenganzira bwo kuronka ubufasha mu rurimi rwawe ata giciro. Kugira uvugishe umusemuzi, akura (833) 639-1634.

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(833) 639-1634.

(833) 639-1634

Oromo (Oromifaa): Sanadi kanaa wajiin walqabaate gaffi kamiyuu yoo qabduu tanaan, Gargaarsa argachuu fi odeeffanoo afaan ketiin kaffaltii alla argachuuf mirgaa qabdaa. Turjumaana dubaachuuf, (833) 639-1634 bilbilla.

Pennsylvania Dutch (Deitsch): Wann du Frooge iwwer selle Document hoscht, du hoscht die Recht um Helfe un Information zu griege in dei Schprooch mitaus Koscht. Um mit en Iwwersetze zu schwetze, ruff (833) 639-1634 aa.

Polish (polski): W przypadku jakichkolwiek pytań związanych z niniejszym dokumentem masz prawo do bezpłatnego uzyskania pomocy oraz informacji w swoim języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer (833) 639-1634.

Portuguese (Português): Se tiver quaisquer dúvidas acerca deste documento, tem o direito de solicitar ajuda e informações no seu idioma, sem qualquer custo. Para falar com um intérprete, ligue para (833) 639-1634.

(833) 639-1634

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Language Access Services:

(833) 639-1634.

Samoan (Samoa): Afai e iai ni ou fesili e uiga i lenei tusi, e iai lou ‘aia e maua se fesoasoani ma faamatalaga i lou lava gagana e aunoa ma se totogi. Ina ia talanoa i se tagata faaliliu, vili (833) 639-1634.

Serbian (Srpski): Ukoliko imate bilo kakvih pitanja u vezi sa ovim dokumentom, imate pravo da dobijete pomoć i informacije na vašem jeziku bez ikakvih troškova. Za razgovor sa prevodiocem, pozovite (833) 639-1634.

Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar con un intérprete, llame al (833) 639-1634.

Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Makipag-usap sa isang tagapagpaliwanag, tawagan ang (833) 639-1634.

Thai (ไทย): หากท่านมีคําถามใดๆ เกี่ยวกับเอกสารฉบับนี้ ท่านมีสทธิ์ที่จะไดิ ้รับความชวยเหลือและข่ ้อมูลในภาษาของท่านโดยไม่มีค่าใชจ่าย้ โดยโทร (833) 639-1634 เพื่อพูดคุยกับล่าม

(833) 639-1634.

(833) 639-1634

Vietnamese (Tiếng Việt): Nếu quý vị có bất kỳ thắc mắc nào về tài liệu này, quý vị có quyền nhận sự trợ giúp và thông tin bằng ngôn ngữ của quý vị hoàn toàn miễn phí. Để trao đổi với một thông dịch viên, hãy gọi (833) 639-1634.

. (833) 639-1634

(833) 639-1634.

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Language Access Services: It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368- 1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

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City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2019 – 03/31/2020

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family| Plan Type: Drug

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.caremark.com or by calling 1-800-552-8159.

Important Questions Why this Matters: What is the overall $0 See the chart starting on page 2 for your costs for services this plan covers. deductible? Are there other You don’t have to meet deductibles for specific services, but see the chart starting on page No. deductibles for specific 2 for other costs for services this plan covers. services? Is there an out–of– Yes. $2,000 Person / $4,000 The out-of-pocket limit is the most you could pay during a coverage period (usually one pocket limit on my Family year) for your share of the prescription copays. expenses? What is not included in the out–of–pocket Medical Copays limit? Is there an overall annual limit on what No the plan pays? For a list of retail pharmacies, log on to Caremark.com and use the Find a Pharmacy tool. Does this plan use a Yes. For mail order prescriptions, use Start Mail Service or Refill Mail Service Prescriptions network of providers? after logging on to Caremark.com. A list of specialty pharmacies is also available. Do I need a referral to No see a specialist? Are there services this For a list of excluded drugs, log on to Caremark.com and use the Understand My Plan and Yes. plan doesn’t cover? Benefits tab.

Questions: Call 1-800-776-1355 or visit us at www.caremark.com. OMB Control Numbers 1545-2229, If you aren’t clear about any of the bolded terms used in this form, see the Glossary at the HR Department. 1210-0147, and 0938-1146 1 of 6 . City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2019 – 03/31/2020

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family| Plan Type: Drug

• Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. • Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your deductible. • The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) • This plan may encourage you to use in network providers by charging you lower deductibles, co-payments and co-insurance amounts.

Your cost if you use an Common Services You May Need Limitations & Exceptions Medical Event In-network Out-of-network Provider Provider Primary care visit to treat an injury or illness ------NA------NA------If you visit a health Specialist visit ------NA------NA------care provider’s office or clinic Other practitioner office visit ------NA------NA------Preventive care/screening/immunization ------NA------NA------Diagnostic test (x-ray, blood work) ------NA------NA------If you have a test Imaging (CT/PET scans, MRIs) ------NA------NA------

If you need drugs to Generic copay – retail / Rx $10 Does Not Apply Covers up to a 30-day supply treat your illness or Generic copay – mail order / Rx $20 Does Not Apply Covers up to a 90-day supply condition Preferred copay – retail / Rx $25 Does Not Apply Covers up to a 30-day supply More information Preferred copay – mail order / Rx $50 Does Not Apply Covers up to a 90-day supply about prescription drug coverage is Non-Preferred copay – retail / Rx $40 Does Not Apply Covers up to a 30-day supply available at www.caremark.com Non-Preferred copay – mail order / Rx $80 Does Not Apply Covers up to a 90-day supply

Questions: Call 1-800-776-1355 or visit us at www.caremark.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary at the HR Department. 2 of 6 . City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2019 – 03/31/2020

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family| Plan Type: Drug

Your cost if you use an Common Services You May Need Limitations & Exceptions Medical Event In-network Out-of-network Provider Provider If you have Facility fee (e.g., ambulatory surgery center) ------NA------NA------outpatient surgery Physician/surgeon fees ------NA------NA------

If you need Emergency room services ------NA------NA------immediate medical Emergency medical transportation ------NA------NA------attention Urgent care ------NA------NA------If you have a Facility fee (e.g., hospital room) ------NA------NA------hospital stay Physician/surgeon fee ------NA------NA------

If you have mental Mental/Behavioral health outpatient services ------NA------NA------health, behavioral Mental/Behavioral health inpatient services ------NA------NA------health, or substance Substance use disorder outpatient services ------NA------NA------abuse needs Substance use disorder inpatient services ------NA------NA------Prenatal and postnatal care ------NA------NA------If you are pregnant Delivery and all inpatient services ------NA------NA------Home health care ------NA------NA------

If you need help Rehabilitation services ------NA------NA------recovering or have Habilitation services ------NA------NA------other special health Skilled nursing care ------NA------NA------needs Durable medical equipment ------NA------NA------Hospice service ------NA------NA------Eye exam ------NA------NA------If your child needs Glasses ------NA------NA------dental or eye care Dental check-up ------NA------NA------

Questions: Call 1-800-776-1355 or visit us at www.caremark.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary at the HR Department. 3 of 6 . City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2019 – 03/31/2020

Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Family| Plan Type: Drug Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

• Please note – When a generic is available, but the pharmacy dispenses the brand-name medication for any reason, you will pay the difference between the brand-name medication and the generic plus the generic copayment.

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

• ------NA------NA------NA------

Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at 216-664-3496. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 1-877-267-2323 x61565 or www.cciio.cms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: 216-664-3496. ––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

Questions: Call 1-800-776-1355 or visit us at www.caremark.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary at the HR Department. 4 of 6 . City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2015 – 03/31/2016 Coverage Examples

About these Coverage Having a baby Managing type 2 diabetes (normal delivery) (routine maintenance of

Examples: a well-controlled condition)

These examples show how this plan might cover  Amount owed to providers: $7,540  Amount owed to providers: $4,100 medical care in given situations. Use these  Plan pays$  Plan pays $ examples to see, in general, how much financial  Patient pays Applicable Copay  Patient pays Applicable Copay protection a sample patient might get if they are covered under different plans. Sample care costs: Sample care costs: Hospital charges (mother) $0 Prescriptions $Copay Routine obstetric care $0 Medical Equipment and Supplies $0 Hospital charges (baby) $0 Office Visits and Procedures $0 This is Anesthesia $0 Education $0 not a cost Laboratory tests $0 Laboratory tests $0

estimator. Prescriptions $Copay Vaccines, other preventive $0

Radiology $0 Don’t use these examples to Total Copays estimate your actual costs Vaccines, other preventive $0 under this plan. The actual Total Copays Patient pays: care you receive will be Deductibles $0 different from these Patient pays: Co-pays $0 examples, and the cost of Deductibles $0 Co-insurance $0 that care will also be Co-pays $0 Limits or exclusions $0 different. Co-insurance $0 Total Copays See the next page for Limits or exclusions $0 important information about Total Copays these examples.

Questions: Call 1-800-776-1355 or visit us at www.caremark.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary at the HR Department. 5 of 6 . City of Cleveland: CVS Caremark Prescription Drug Plan Coverage Period: 04/01/2015 – 03/31/2016 Coverage Examples Questions and answers about the Coverage Examples:

What are some of the What does a Coverage Example Can I use Coverage Examples assumptions behind the show? to compare plans? Coverage Examples? For each treatment situation, the Coverage Yes. When you look at the Summary of Example helps you see how , deductibles co- Benefits and Coverage for other plans, • Costs don’t include premiums. , and can add up. It payments co-insurance you’ll find the same Coverage Examples. • Sample care costs are based on national also helps you see what expenses might be left When you compare plans, check the averages supplied by the U.S. up to you to pay because the service or “Patient Pays” box in each example. The Department of Health and Human treatment isn’t covered or payment is limited. Services, and aren’t specific to a smaller that number, the more coverage particular geographic area or health plan. the plan provides. • The patient’s condition was not an Does the Coverage Example excluded or preexisting condition. predict my own care needs? Are there other costs I should • All services and treatments started and consider when comparing ended in the same coverage period.  No. Treatments shown are just examples. plans? • There are no other medical expenses for The care you would receive for this any member covered under this plan. condition could be different based on your doctor’s advice, your age, how serious your Yes. An important cost is the premium • Out-of-pocket expenses are based only condition is, and many other factors. you pay. Generally, the lower your on treating the condition in the example. premium, the more you’ll pay in out-of- • The patient received all care from in- pocket costs, such as co-payments, network providers. If the patient had Does the Coverage Example deductibles, and co-insurance. You received care from out-of-network should also consider contributions to

providers, costs would have been higher. predict my future expenses? accounts such as health savings accounts (HSAs), flexible spending arrangements No. Coverage Examples are not cost estimators. You can’t use the examples to (FSAs) or health reimbursement accounts estimate costs for an actual condition. They (HRAs) that help you pay out-of-pocket are for comparative purposes only. Your expenses. own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows.

Questions: Call 1-800-776-1355 or visit us at www.caremark.com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary at the HR Department. 6 of 6 .

SCHEDULE OF BENEFITS

Policyholder: City of Cleveland

An Insured Persons has the right to obtain vision care from the Provider of his or her choice. Benefits are payable as shown in the following Schedule of Benefits:

Out-of-Network Benefit In-Network Costs Benefit Frequency Reimbursements VISION EXAMINATION Under age 20, once every 12 month Comprehensive Eye Examination $10 Co-payment up to $30 Age 20 and over, once every 24 months Under age 20, once every 12 month Contact Lens Fit and Follow Up Age 20 and over, once every 24 months Standard $0 Co-payment up to $40 Premium $0 Co-payment, less $40 allowance up to $40

VISION MATERIALS Under age 20, once Standard Plastic Lenses every 12 month Age 20 and over, once every 24 months Single Vision $0 Co-payment up to $30

Bifocal $0 Co-payment up to $40

Trifocal $0 Co-payment up to $50

Lenticular $0 Co-payment up to $50 Under age 20, once every 12 month Frames $0 Co-payment, up to $120 retail allowance up to $60 Age 20 and over, once every 24 months Under age 20, once every 12 month Contact Lenses (only one option available per Benefit Frequency) Age 20 and over, once every 24 months Conventional $0 Co-payment, up to $75 allowance up to $60

Disposable $0 Co-payment, up to $75 allowance up to $60

Medically Necessary $0 Co-payment, Paid in full up to $200 Under age 20, once Lens Options every 12 month Age 20 and over, once every 24 months Tint: Solid or Gradient $0 Co-payment up to $6 Standard Progressive Lenses (add on to $60 Co-payment up to $40 Bifocal) Premium Progressive Lenses (add on to $60 Co-payment, less $110 allowance up to $40 Bifocal)

VN S63007 1108 1A

Trustmark Accident Insurance

Coverage for when life takes a tumble.

Helping you prepare for the unexpected

Accidents happen. And medical insurance deductibles are going up, which can make sudden expenses like Benefits for injury and care the medical costs associated with an accidental injury Accident insurance pays based on your injury and the harder for your family to deal with. care you receive. Benefits are included for medical services, including: Trustmark Accident insurance pays cash directly to you for treatment for covered accidents. The plan pays regardless of other coverage you have, and there are no restrictions on how you may use the money. • Hospital admissions • Prosthetic devices • Ambulance transport or artificial limbs With Accident insurance, you can worry less about your • Physical therapy • Skin grafts bills, and focus on recovering. … and for covered injuries, like:

• Fractures • Concussion Accident sample rates • Dislocations • Amputations The chart below lists sample weekly rates across all Trustmark plans • Burns nationwide, which vary by benefit amounts payable. These are just examples. A complete schedule of Covered person(s) Rates benefits will be listed in your policy. Employee from $2.28 – $5.39 Employee + Spouse from $3.29 – $8.01 Accident insurance pays you directly Employee + Child(ren) from $4.95 — $10.15 Trustmark Accident insurance can be used any way you like, to help you pay for things like: Family from $5.96 — $12.77 • Deductibles • Transportation and Sample rates are shown for illustrative purposes only. Rates may vary by lodging costs state, employer and features selected by you and/or by your employer. An • Co-payments application for insurance must be completed to obtain coverage. • Everyday bills

Accident insurance offers 24-hour coverage for certain Your affordable rate isn’t based on accidental injuries, as well as for your age - and it will never increase for medical care and equipment to treat them. as long as you have the policy.

See reverse for more information on Accident insurance from Trustmark Insurance Company. Are you prepared to deal with an injury?

About 40 million visits to the US emergency rooms each year are injury-related.1

1 National Center for Health Statistics, 2014.

Additional advantages More flexible features • Apply for coverage for family members: spouse, • Get paid for routine physicals, immunizations, and children, and dependent grandchildren. health screening tests. • There are no medical questions to enroll, though • Receive a lump sum payment in the event of the spouses will need to answer a disability question death of an insured person by a covered accident. if they choose to enroll.

• Keep your coverage if you leave your job with no A waiting period may apply before benefits are payable. Feature availability change in premium or benefits. may vary by state. • Convenient payroll deduction, or pay via direct bill, bank draft or credit card if you leave your employer.

This is a brief description of benefits under A-607 and applicable riders WB-607, HS-12000R, and LCWP-5/01. This is an accident only policy with limited benefits and does not pay benefits for diseases, sickness, or for loss from sickness. This is not a workers’ compensation policy or a substitute for medical expense insurance, major medical insurance or a health benefit plan alternative. It is also not a Medicare Supplement policy. Please refer to your policy/group certificate and outline of coverage, if applicable, for complete information. Limitations on pre-existing conditions may apply. Benefits, definitions, exclusions, form numbers and limitations may vary by state. For costs and coverage detail, including exclusions, limitations and terms, see your agent or write the company. Underwriting conditions may vary, and determine eligibility for the offer of insurance. For exclusions and limitations that may apply, visit www.trustmarksolutions.com/disclosures/ACC/ (A112-2216-ACC). 2An A.M. Best rating is an independent opinion of an insurer’s financial strength and ability to meet its ongoing insurance policy and contract obligations. Trustmark is rated A- (4th out of 16 possible ratings ranging from A++ to Suspended).

Underwritten by Trustmark Insurance Company Rated A- (EXCELLENT) A.M. Best2 trustmarksolutions.com

Initial Care Injuries Hospital Benefits Fractures Admission Benefit (per admission) $1,000 Open reduction Up to $5,000 Confinement Benefit (per day up to 365 days) $200 Closed reduction Up to $2,500 ICU Benefit (per day up to 15 days) $400 Chips 25% of applicable Emergency Room Treatment $150 closed reduction Ambulance Dislocations Ground $100 Open reduction Up to $4,000 Air $500 Closed reduction Up to $2,000 Initial Doctor’s Office Visit $50 Laceration Up to $400 Lodging (per night up to 30 days per accident) $100 Burns Surgery Benefit Flat amount for: Open, abdominal, thoracic $1,000 Third-degree 35 or more sq. in. $10,000 Exploratory $100 Third-degree 9-34 sq. in. $1,500 Blood, Plasma and Platelets $300 Second-degree for 36% or more of body $750 Emergency Dental Benefit Concussion $100 Extraction $50 Eye Injury Crown $150 Requires surgery or removal of foreign body $200 Follow-Up Care Herniated Disc $400 Accident Follow-Up Treatment $50 Loss of Finger, Toe, Hand, Foot or Sight Physical Therapy Loss of both hands, feet, sight of both eyes Up to six visits per person per accident $25 or any combination of two or more losses $15,000 Appliance $100 Loss of one hand, foot or sight of one eye $7,500 Transportation Loss of two or more fingers, toes or any 100+ miles, up to three trips $300 combination of two or more losses $1,500 Prosthetic Device or Artificial Limb Loss of one finger or one toe $750 More than one $1,000 Tendon/Ligament/Rotator Cuff Injury One $500 Repair of more than one $600 Skin Grafts 25% of applicable Repair of one $400 burn benefit Exploratory surgery without repair $100 Accidental Death Torn Knee Cartilage $500 Exploratory surgery $100 Employee $25,000 3 Spouse $10,000 Wellness Benefit Child $5,000 Two per person/10 per family annually $50 Accidental Death – Common Carrier Routine physicals, immunizations and health screening tests. 60-day waiting period applies in most states. Employee $50,000 3 Spouse $20,000 Child $10,000

1Benefits are payable only as the result of a covered accident. Benefits may vary by state and additional benefits may be available in some states. Most benefits are paid once per person per covered accident unless otherwise noted. 3In some states, spouse, domestic partner or civil union partner. AP3-24-ADB-WELL50 Insert Trustmark Critical Illness Insurance Providing a financial cushion for when you need it most.

Helping pay for what health insurance doesn’t A serious illness can be hard on more than just your Coverage for an array of illnesses health: it can threaten you and your family’s financial Trustmark Critical Illness insurance pays a lump-sum stability. Even with medical insurance, you may have 1 benefit if you are diagnosed with any of several out-of-pocket payments and other new major expenses. 2 conditions , including: You might even have less income to cover these costs. Critical Illness insurance can help. • Heart attack • Major organ transplant Critical Illness insurance pays a lump sum of cash • Stroke • Paralysis of two or directly to you when you are diagnosed with a covered • Invasive cancer more limbs illness – use it for whatever you need. (excludes most skin • Coronary artery With Critical Illness insurance, if you are affected by a cancer) bypass surgery (at 3 major illness, you can focus on your health with less • Renal (kidney) failure 25% benefit) worry about your wallet. • Blindness • Carcinoma in situ (at 25% benefit) 3 • ALS (Lou Gehrig’s disease) Critical Illness sample rates Sample ranges of weekly rates for employee-only, non-tobacco coverage. Your exact rate may depend on additional features selected by you and/ Benefits can help you pay for: or by your employer. Medical Credit card bills deductibles and Age at purchase $15,000 policy co-pays Rent or mortgage 30 from $3.00* – $4.19 Out-of-network payments 40 from $3.70 – $6.08 or alternative Child care 50 from $6.73 – $11.31 treatment Travel to Sample base rates are shown for illustrative purposes only. Rates may vary Tuition and loans by age, tobacco use, state, employer and features selected by you and/or by treatment your employer. An application for insurance must be completed to obtain 1 coverage. *Minimum weekly premium is $3. Benefit will be adjusted up if Most states define eligibility as first diagnosis, meaning the first time a physician identifies a covered condition from its signs or symptoms. If you’ve $3 purchases more than $15,000 in benefit. been diagnosed with a covered condition prior to having coverage, you may not be eligible for a benefit.2 Please consult your policy/group certificate for Note: once you have a policy, your rates will not increase due to age. specific covered conditions.3 If the insured receives the 25% benefit for coronary artery bypass surgery or carcinoma in situ, the remaining benefit will be available for a diagnosis of another covered condition or subsequent benefit, if included. Most skin cancer is excluded.

See reverse for more information on Critical Illness insurance from Trustmark Insurance Company. Cardiovascular disease and stroke More than a quarter of adults $316 cost Americans more than in the U.S. say health care costs $316 billion in direct and have caused them a serious financial Billion indirect costs annually.4 problem in the last two years.5

Additional advantages More flexible features • Access to medical experts. • A health screening benefit will • Receive additional benefit Critical Illness includes access pay the cost of one screening payments if you get sick again to Best Doctors®, the network test per year ($100 maximum.) with different covered illnesses. of top doctors in the world, for Some of the many eligible tests A payout is available for each new free medical advice, second include: diagnosed condition, and the amount paid never reduces.6 opinions, critical care support • Low-dose mammography and more. • Pap smear (women 18+) • Keep your coverage at the • Serum cholesterol same price and benefits if you • Prostate-specific antigen change jobs or retire. • Stress test • Apply for coverage for family • Colonoscopy members: spouse, children • Chest X-ray and dependent grandchildren. • Bone marrow test • Convenient payroll deduction: pay via direct bill, bank draft or credit card if you leave your employer.

Pre-existing condition limitation No benefit will be paid for any condition caused by or resulting from a pre-existing condition.

This is a brief description of benefits under CACI-82001 and applicable riders HS-12000, WP-12000, HIV 806, SB 806, EZ-12000R, SC 511, SCR 511, SCRC 511, and MCPRS0-ME. This critical illness/specified disease insurance policy/group certificate provides supplemental health insurance coverage, which pays a limited, lump-sum benefit for specified diseases only. It is not a substitute for medical expense insurance, major medical expense insurance or a health benefit plan alternative. It does not provide comprehensive medical coverage. It is not intended to pay all medical costs associated with the specified diseases and is not designed to provide coverage for other medical conditions or illnesses. It is also not a Medicare Supplement policy, nor is it a policy of worker’s compensation. Please refer to your policy/group certificate and outline of coverage, if applicable, for complete information. Limitations on pre-existing conditions may apply. A waiting period may apply before benefits are payable. Benefits, definitions, exclusions, form numbers and limitations may vary by state. For costs and coverage detail, including exclusions, limitations and terms, see your agent or write the company. Underwriting conditions may vary, and determine eligibility for the offer of insurance. For exclusions and limitations that may apply, visit www.trustmarksolutions.com/disclosures/CI/ (A112-2216-CI). 4Heart Disease, Stroke and Research Statistics At-a-Glance. American Heart Association. 2016. 5“Medical Bills Still Take a Big Toll, Even with Insurance.” NPR. March 8, 2016. 6Separation periods between diagnoses may apply. 8An A.M. Best rating is an independent opinion of an insurer’s financial strength and ability to meet its ongoing insurance policy and contract obligations. Trustmark is rated A- (4th out of 16 possible ratings ranging from A++ to Suspended).

Underwritten by Trustmark Insurance Company Rated A- (EXCELLENT) A.M. Best8 trustmarksolutions.com

Protecting your paycheck even when you can’t work.

What would you do without a paycheck? Your salary is crucial for taking care of yourself and the people who depend on you. But a nasty injury or illness could leave you unable to do your job – and unable to collect an income. Money trouble is the last thing you need when trying to get well. Disability Income insurance can help. Covered conditions When you are disabled1 and unable to work due Disability Income insurance covers total disability due to:2 to a sickness or off-the-job injury, Disability Income • Non-occupational sickness insurance replaces part of your paycheck. It provides a regular cash benefit that you can use for all the things • Non-occupational injury your salary typically pays for. • Pregnancy (10 months after effective date)

Disability Income insurance goes to work when you • Complications of pregnancy can’t, helping ensure that your life can keep running smoothly even when you are temporarily off your feet. What can benefits help pay for? You can use your Disability Income benefits for whatever you need, including: Disability Income sample rates Rent or mortgage Sample ranges of weekly rates for 3-month coverage with a 14-day Groceries and elimination period for disability due to either injury or illness. payments personal care Credit card bills Age at purchase $1,000 monthly benefit Tuition and loans 17-49 $4.30 - $6.10 Child care and Medical deductibles 50-59 $5.10 - $7.00 housekeeping and copays 60-67* $6.70 – $8.70 *Maximum issue age may vary by state. How benefits add up Sample base rates are shown for illustrative purposes only. Rates may Example: Jaime, who has a $1,000/month Disability Income policy,

vary by age, state, employer, and features selected by you and/or by slipped a disc in his back and was unable to work for two and a half your employer. An application for insurance must be completed to months following his elimination period: obtain coverage. Benefits paid First month of disability Note: once you have a policy, your rates will not increase due to age. $1,000 following elimination period Second month of disability $1,000 1As defined by policy/certificate. 2Benefit payment is subject to terms Last 15 days of disability $500 and conditions of coverage. Pre-existing condition limitations may apply. Total benefits paid3 $2,500 3Benefits paid may vary. See your policy/certificate for details.

See reverse for more information on Disability Income insurance from Trustmark Insurance Company.

1 of 4 of today’s 78% of American workers 20-year-olds will experience 78% live paycheck to paycheck a disability before reaching age 67.4 to make ends meet.5

Additional advantages Total disability defined • Benefits paid in full, at the Disability Income insurance pays benefits for total disability, meaning you are: same frequency as your • Unable to work at your job. paycheck, regardless of other coverage. (A monthly payment • Not working at your current employer. option is available.) • Under a doctor’s care for the injury or covered sickness causing your • Coverage for time off of work disability. due to pregnancy/childbirth 10 months after the coverage Coverage and elimination periods effective date, or due to Your coverage period is the length of time for which you are able to collect complications of pregnancy. benefits. There may be a period after you become disabled before your • Waive your premium payments benefits begin, known as the elimination period. if you remain disabled for Coverage and eliminations periods vary by employer. You may also be able more than 90 consecutive days to choose between multiple options. More information on these periods will during the benefit period. be available to you at your time of enrollment. • Keep your coverage at the same price and benefits if you change jobs or retire. Coverage ends at age 72. • Convenient payroll deduction: pay via direct bill, bank draft or credit card if you leave your employer.

This is a brief description of benefits under DI-902 and applicable riders. This insurance policy/group certificate provides coverage for disabilities resulting from covered accidents or covered sicknesses. It is not a substitute for medical expense insurance, major medical expense insurance or a health benefit plan alternative. It is also not a Medicare Supplement policy, nor is it a policy of worker’s compensation. Please refer to your policy/group certificate and outline of coverage, if applicable, for complete information. Limitations on pre-existing conditions may apply. A waiting period may apply before benefits are payable. Benefits, definitions, exclusions, form numbers and limitations may vary by state. For costs and coverage detail, including exclusions, limitations and terms, see your agent or write the company. Underwriting conditions may vary, and determine eligibility for the offer of insurance. For exclusions and limitations that may apply, visit www.trustmarksolutions.com/disclosures/ DI/ (A112-2216-DI). 4Social Security Administration, “Disability Planner: Social Security Protection If You Become Disabled.” 5CareerBuilder, “Living Paycheck to Paycheck is a Way of Life for Majority of U.S. Workers, According to New CareerBuilder Survey.” 7An A.M. Best rating is an independent opinion of an insurer’s financial strength and ability to meet its ongoing insurance policy and contract obligations. Trustmark is rated A- (4th out of 16 possible ratings ranging from A++ to Suspended).

Underwritten by Trustmark Insurance Company Rated A- (EXCELLENT) A.M. Best7 trustmarksolutions.com benefits beyond benefits

Voluntary Benefits The way people pay for their healthcare is changing. Many employers are offering new and different health insurance plans, including high-deductible options. Whatever you choose, the Health Screening Benefit included in your Trustmark plan can pay you for getting one screening test per calendar year.

Here’s how it works: when you file a claim for one of the screening tests listed below, Trustmark will send you a check even if your insurance covers these tests at no cost as part of your employee wellness program. No waiting period from the effective date of this benefit.

• Fasting blood • Cardiac stress test glucose test • Bone marrow testing • Blood test for • Chest x-ray triglycerides • Hemoccult stool • Serum cholesterol test specimen to determine levels of HDL and LDL • CA 15-3 blood test for breast cancer • Routine mammogram • CA 125 blood test for ovarian cancer • Pap smear (for women over age 18) • CEA blood test for colon cancer • Prostate Specific Antigen (PSA) for • Serum Protein prostate cancer Electrophoresis (SPEP) blood test for • Colonoscopy myeloma • Flexible • Thermography sigmoidoscopy File Your Claim To file a claim, simply visit the following website: www.trustmarksolutions.com/file-claim You will find a fillable Health Screening Rider claim form, which you can submit by email to [email protected] or by fax to 508.471.3208. During enrollment, a benefit counselor will be available to answer any additional questions you may have. If you have questions after you receive your policy, call us at 800.918.8877.

Health Screening Rider HS-12000/R is a part of Critical Illness Insurance Plan Form CACI-82001 and Accident Insurance Plan Form A-607, underwritten by Trustmark Insurance Company, Lake Forest, Illinois. Please see your Rider and Rider Schedule for your state for exact terms, provisions, exclusions and limitations that apply. 1 An A.M. Best rating is an independent opinion of an insurer’s financial strength and ability to meet its ongoing insurance policy and contract obligations. Trustmark is rated A- (4th out of 16 possible ratings ranging from A++ to Suspended).

Underwritten by Trustmark Insurance Company Rated A- (EXCELLENT) A.M. Best1 400 Field Drive • Lake Forest, IL 60045 trustmarksolutions.com © 2018 Trustmark Insurance Company, Lake Forest, IL A112-659 (11-18)P Trustmark Universal Life Insurance with Long-Term Care Benefit

Two important coverages in one to help protect you for life.

Financial security even after a loss Protecting your loved ones is one of life’s greatest responsibilities. When a family loses someone, in addition to grief, survivors may suddenly be faced with costly expenses and debts, and even a loss of income. Universal Life can help. Whether you are married, a parent or single and Solving the long-term care issue starting out, Universal Life helps take care of the people At any point in your life, you may need long-term care important to you if tragedy happens. You can choose services, which could cost hundreds of dollars per day. a benefit amount that provides the right protection Universal Life includes a long-term care (LTC) benefit for you. that can help pay for these services at any age. Universal Life insurance can mean those left behind Here’s how it works: can still pursue their own dreams, and help ensure that the ending of one story won’t stop the beginning You can collect 4% of your Universal Life of another. benefit per month for up to 25 months to help pay for long-term care services. Universal Life sample rates Flexible features available: Sample ranges of weekly rates for employee-only, non-smoker coverage. Your exact rate may depend on additional features selected PLUS: If you collect a benefit for LTC, your by you and/or by your employer. full death benefit is still available for your beneficiaries, as much as doubling Age at purchase $25,000 policy your benefit. 30 from $5.06 – $6.27

40 from $7.42 – $9.44 The LTC Benefit is an acceleration of the death benefit and is not Long- 50 from $11.92 – $15.44 Term Care Insurance (except in LA, where the LTC benefit is Long-Term Care Insurance.) It begins to pay after 90 days of confinement or services, Sample rates are shown for illustrative purposes only. Rates may vary by and to qualify you must meet conditions of eligibility for benefits. age, smoking status, state, employer and features selected by you and/ Pre-existing condition limitation may apply. Benefits may not be or by your employer. An application for insurance must be completed to available in all states or may be named differently. Your policy will obtain coverage. contain complete details.

Universal Life is flexible permanent The younger you are when you enroll, No medical exams or blood work – life insurance designed the more benefit you receive just answer a few simple questions. to last a lifetime. for the same premium.

See reverse for more information on Universal Life insurance from Trustmark Insurance Company. What would happen if you weren’t around?

1 in 3 households would 40% of Americans live 56% of Americans have have immediate trouble 40% paycheck to paycheck. less than $10,000 saved for paying for living expenses Could your family afford retirement – 1 in 3 have $0 if they lost their primary to stay in your home?2 saved. Wouldn’t it be nice earner.1 to have some protection?3

What can Universal Life Additional advantages More flexible features benefits help pay for? • Keep your coverage at the • Double your death same price and benefits if you benefit if you die in an Funeral and change jobs or retire. accident before age 75. burial costs • Apply for coverage for family Rent or mortgage members: spouse, children payments and grandchildren.

Tuition and loans • Convenient payroll deduction; pay via direct bill, Credit card bills bank draft or credit card if you leave your employer. Medical expenses

Retirement savings Plus: grow your benefit with EZ Value The EZ Value option can automatically increase your benefit amount over Benefit for terminal illness time – without any medical questions. • Use part of your death Example: $1 increase benefit if you’re diagnosed in weekly premium $25,000 $41,299 $53,845 with a terminal illness to help Initial benefit After 5 years After 10 years each year, for 10 years. manage costs. Example is for age 40, employee only, non-smoker coverage, with long-term care benefit and no additional features. Actual values will vary by age, smoking status, benefits selected and interest rates. Increases may be available for a maximum of 5 or 10 years, depending on employer selection.

This is a brief description of benefits under GUL.205/IUL.205 and applicable riders HH/LTC.205, BRR.205, BXR.205, ABR.205, ADB.205, CT.205 and WP.205. Benefits, exclusions, form numbers and limitations may vary by state. This policy guarantees against lapsing for 10 years as long as planned premiums are paid. If you make changes during this period, or pay only the minimum amount, your cash value may not accumulate, or your death benefit may reduce. If there is negative cash value at the end of your no-lapse period, you must make up the premium to establish positive cash value. You may need to pay more premium to maintain your policy than the rate you paid to keep the no-lapse guarantee, or coverage may end before age 100. An illustration will be delivered with your policy. For costs and coverage detail, including exclusions, reductions, limitations and terms, see your agent or write the company. Underwriting conditions may vary, and determine eligibility for the offer of insurance. For exclusions and limitations that may apply, visit www.trustmarksolutions.com/disclosures/UL/ (A112-2216-UL). In California, review “A Consumer’s Guide to Long-term Care from the Department of Aging” at:http://www.aging.ca.gov/aboutcda/publications/Taking_Care_of_Tomorrow_English/. 12016 Insurance Barometer Study LIMRA/Life Happens, lifehappens.org/industryresources/agent/barometer2016. 2nielsen.com/us/en/insights/news/2015/ saving-spending-and-living-paycheck-to-paycheck-in-america.html. 3gobankingrates.com/retirement/1-3-americans-0-saved-retirement. 5 An A.M. Best rating is an independent opinion of an insurer’s financial strength and ability to meet its ongoing insurance policy and contract obligations. Trustmark is rated A- (4th out of 16 possible ratings ranging from A++ to Suspended).

Underwritten by Trustmark Insurance Company Rated A- (EXCELLENT) A.M. Best5 trustmarksolutions.com

Two important coverages for when you need them the most.

Financial security even after a loss Protecting your loved ones is one of life’s greatest responsibilities. When a family loses someone, in addition to grief, survivors may suddenly be faced with costly expenses and debts, and even a loss of income. Universal LifeEvents can help. Universal LifeEvents provides a higher death benefit during your working years, when your needs and Solving the long-term care issue responsibilities are the greatest. (See reverse for more At any point in your life, you may need long-term care on how Universal LifeEvents works.) You can choose services, which could cost hundreds of dollars per day. a benefit amount that provides the right protection Universal LifeEvents includes a long-term care (LTC) for you. benefit that can help pay for these services at any Universal LifeEvents insurance can mean those left age. This benefit never reduces due to age, so the full behind can still pursue their own dreams, and help amount is always available when you most need it. ensure that the ending of one story won’t stop the Here’s how it works: beginning of another. You can collect 4% of the face amount of your Universal LifeEvents policy per month Universal LifeEvents sample rates for up to 25 months to help pay for long- Sample ranges of weekly rates for employee-only, non-smoker term care services. coverage. Your exact rate may depend on additional features selected by you and/or by your employer. Flexible features available:

PLUS: If you collect a benefit for LTC, your Age at purchase $25,000 policy full death benefit is still available for your 30 from $3.49 – $4.59 beneficiaries, as much as doubling your benefit. 40 from $5.05 – $6.71

50 from $7.84 – $10.71 The LTC Benefit is an acceleration of the death benefit and is not Long-Term Care Sample rates are shown for illustrative purposes only. Rates may vary by Insurance (except in LA, where the LTC benefit is Long-Term Care Insurance.) It age, smoking status, state, employer and features selected by you and/ begins to pay after 90 days of confinement or services, and to qualify you must or by your employer. An application for insurance must be completed to meet conditions of eligibility for benefits. Pre-existing condition limitation may apply. Benefits may not be available in all states or may be named differently. obtain coverage. Your policy will contain complete details.

Universal LifeEvents is flexible permanent The younger you are when you enroll, No medical exams or blood work – life insurance designed the more benefit you receive just answer a few simple questions. to last a lifetime. for the same premium.

See reverse for more information on Universal LifeEvents insurance from Trustmark Insurance Company. What would happen if you weren’t around?

How Universal LifeEvents Additional advantages More flexible features Works • Keep your coverage at the • Double your death • A higher death benefit during same price and benefits if you benefit if you die in an working years. change jobs or retire. accident before age 75. • Full LTC benefits when you’re • Apply for coverage for family most likely to need them. members: spouse, children

and grandchildren. Example: $25,000 policy • Before age 70 Convenient payroll deduction; pay via direct bill, Death benefit $25,000 bank draft or credit card if you LTC benefits $25,000 leave your employer.

After age 70 Death benefit $8,333 Plus: grow your benefit with EZ Value LTC benefits $25,000 The EZ Value option can automatically increase your benefit amount over time – without any medical questions. Death benefit reduces to one-third at the latter of age 70 or the 15th policy anniversary. Example: $1 increase Issue age is 18-64. in weekly premium $25,000 $50,414 $70,077 Initial benefit After 5 years After 10 years each year, for 10 years. Benefit for terminal illness • Use part of your death benefit if Example is for age 40, employee only, non-smoker coverage, with long-term care benefit and no you’re diagnosed with a terminal additional features. Actual values will vary by age, smoking status, benefits selected and interest rates. illness to help manage costs. Increases may be available for a maximum of 5 or 10 years, depending on employer selection.

This is a brief description of benefits under GUL.205/IUL.205 and applicable riders HH/LTC.205, BRR.205, BXR.205, ABR.205, ADB.205, CT.205 and WP.205. Benefits, definitions, exclusions, form numbers and limitations may vary by state. This policy guarantees against lapsing for 15 years as long as planned premiums are paid. If you make changes during this period, or pay only the minimum amount, your cash value may not accumulate, or your death benefit may reduce. If there is negative cash value at the end of your no-lapse period, you must make up the premium to establish positive cash value. You may need to pay more premium to maintain your policy than the rate you paid to keep the no-lapse guarantee, or coverage may end before age 100. An illustration will be delivered with your policy. For costs and coverage detail, including exclusions, reductions, limitations and terms, see your agent or write the company. Underwriting conditions may vary, and determine eligibility for the offer of insurance. For exclusions and limitations that may apply, visit www.trustmarksolutions.com/disclosures/UL/ (A112-2216-UL). In California, review “A Consumer’s Guide to Long-term Care from the Department of Aging” at: http://www.aging.ca.gov/aboutcda/publications/Taking_Care_of_Tomorrow_English/. 12016 Insurance Barometer Study LIMRA/Life Happens, lifehappens.org/industryresources/agent/barometer2016. 2nielsen.com/us/en/insights/news/2015/ saving-spending-and-living-paycheck-to-paycheck-in-america.html. 3gobankingrates.com/retirement/1-3-americans-0-saved-retirement. 5An A.M. Best rating is an independent opinion of an insurer’s financial strength and ability to meet its ongoing insurance policy and contract obligations. Trustmark is rated A- (4th out of 16 possible ratings ranging from A++ to Suspended).

Underwritten by Trustmark Insurance Company Rated A- (EXCELLENT) A.M. Best trustmarksolutions.com

Voluntary Benefits With high-deductible health plans being offered by more employers, you may find yourself paying slightly higher out-of- pocket costs for your medical care.

Your Wellness Benefit can help pay for screening tests, routine physicals or immunizations1, two per person, per calendar year, up to your benefit’s maximum2. If you have family coverage, each family member can use the benefit as well, up to a total of 10 visits per year, per family3. If your insurance covers these tests and exams at no cost as part of your employee wellness program, then the benefit is money in your pocket.

1Partial list. Covered tests may vary by state. 2Benefit varies; see your rider schedule for specific amount. 3For policies issued in FL and WA, family visits per year are unlimited. Filing a Claim To file a claim, simply visit the following website: www.trustmarksolutions.com/file-claim You will find a fillable Wellness Benefit claim form, which you can submit by email to [email protected] or by fax to 508.471.3208. During enrollment, a benefit counselor will be available to answer any additional questions you may have. If you have questions after you receive your policy, call us at 800.918.8877. Wellness Benefit Rider WB-607 is a part of Accident Insurance Plan Form A-607, underwritten by Trustmark Insurance Company, Lake Forest, Illinois. Please see your Rider and Rider Schedule for your state for exact terms, provisions, exclusions and limitations that apply. 1 An A.M. Best rating is an independent opinion of an insurer’s financial strength and ability to meet its ongoing insurance policy and contract obligations. Trustmark is rated A- (4th out of 16 possible ratings ranging from A++ to Suspended).

Underwritten by Trustmark Insurance Company Rated A- (EXCELLENT) A.M. Best1 400 Field Drive • Lake Forest, IL 60045 trustmarksolutions.com © 2019 Trustmark Insurance Company, Lake Forest, IL A112-2174 (2-19) ENROLLMENT : Line of Business Summary

Date Range : JAN 2017 through DEC 2017

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:43:49AM Page 1 of 1 COMPREHENSIVE MAJOR MEDICAL 2 Person : 2 Person : Employee 3 Person : Total Total Month Year Single Emp/Spouse Emp/Child Family /Children Emp/Sp/Child Medifil Contracts Members January 2017 1,322 0 0 2,676 0 0 0 3,998 10,594 February 2017 1,338 0 0 2,669 0 0 0 4,007 10,599 March 2017 1,361 0 0 2,640 0 0 0 4,001 10,591 April 2017 1,606 0 0 2,884 0 0 0 4,490 11,405 May 2017 1,610 0 0 2,862 0 0 0 4,472 11,319 June 2017 1,600 0 0 2,857 0 0 0 4,457 11,293 July 2017 1,575 0 0 2,832 0 0 0 4,407 11,183 August 2017 1,575 0 0 2,821 0 0 0 4,396 11,153 September 2017 1,609 0 0 2,850 0 0 0 4,459 11,258 October 2017 1,607 0 0 2,844 0 0 0 4,451 11,219 November 2017 1,618 0 0 2,838 0 0 0 4,456 11,195 December 2017 1,618 0 0 2,829 0 0 0 4,447 11,137 Total : 18,439 0 0 33,602 0 0 0 52,041 132,946 Average : 1,537 0 0 2,800 0 0 0 4,337 11,079

RTOR0403 Client Reference#: 023040000008 CLAIMS SUMMARY : Payments by Line of Business - Summary All Sections

Report Type : Total Paid Claims - All Sections - Medical Mutual and Employer Paid Claims Combined

Paid : JAN 2017 through DEC 2017 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:40:55AM Page 1 of 1

SUMMARY LINK TO : CHART ALL SECTIONS Jan - 2017 Feb - 2017 Mar - 2017 Apr - 2017 May - 2017 Jun - 2017 Jul - 2017 Aug - 2017 Sep - 2017 Oct - 2017 Nov - 2017 Dec - 2017 Total

Comprehensive 3,245,728 3,558,618 4,809,395 3,511,142 4,081,238 3,767,494 3,963,240 3,522,254 4,111,647 3,731,654 3,772,675 3,338,372 45,413,456 Major Medical

Total 3,245,728 3,558,618 4,809,395 3,511,142 4,081,238 3,767,494 3,963,240 3,522,254 4,111,647 3,731,654 3,772,675 3,338,372 45,413,456

This report displays paid claims information only. The report does not include employer payments toward deductible or coinsurance. RTOR0411 Client Reference#: 023040000008 CLAIMANT ANALYSIS : High Cost Claimant Summary Medical All - By Payments : $ 50,000 +

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 1 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****5139 F ACTIVE YES $485,386 $485,386 OTHER SEPSIS (BLOOD INFECTIOUS AND INFECTIONS) PARASITIC ****0300 M CANCEL YES $480,167 $480,167 CANCER: MULTIPLE MYELOMA AND NEOPLASMS PLASMA CELL NEOPLASMS ****8928 F ACTIVE YES $459,173 $459,173 OTHER PULMONARY HEART CIRCULATORY DISEASES SYSTEM ****4924 F CANCEL YES $405,661 $405,661 CARDIAC ARREST CIRCULATORY SYSTEM ****9433 M CANCEL YES $398,206 $398,206 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****7027 F ACTIVE YES $396,159 $396,159 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****7771 F CANCEL YES $360,221 $360,221 HERNIA: UNSPECIFIED ABDOMINAL DIGESTIVE SYSTEM

****9429 M ACTIVE YES $330,986 $330,986 NONTRAUMATIC SUBARACHNOID CIRCULATORY HEMORRHAGE (BLEEDING IN THE SYSTEM AREAS SURROUNDING THE BRAIN) ****8032 M ACTIVE $309,239 $309,239 CANCER: RECTOSIGMOID NEOPLASMS

****9993 M ACTIVE YES $300,246 $300,246 CANCER: CONNECTIVE AND SOFT NEOPLASMS TISSUE ****2096 M ACTIVE $273,086 $273,086 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****3357 F ACTIVE YES $247,866 $247,866 EPILEPSY AND RECURRENT NERVOUS SYSTEM SEIZURES

*A "YES" in the "Referred to Case Mgmt" column may not indicate enrollment in a Case Management program. RTOR0902 Client Reference#: 023040000008 CLAIMANT ANALYSIS : High Cost Claimant Summary Medical All - By Payments : $ 50,000 +

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 2 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****3883 F ACTIVE YES $233,743 $233,743 CANCER: BREAST NEOPLASMS

****7407 M ACTIVE YES $229,515 $229,515 ATHEROSCLEROSIS (PLAQUE BUILD CIRCULATORY UP IN BLOOD VESSELS AKA SYSTEM HARDENING OF THE ARTERIES) ****7127 M ACTIVE $221,908 $221,908 CANCER: PANCREAS NEOPLASMS

****6450 M ACTIVE YES $213,923 $213,923 CANCER: ESOPHAGUS NEOPLASMS

****6526 M ACTIVE YES $205,157 $205,157 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****3677 F ACTIVE $201,016 $201,016 ACUTE AND SUBACUTE CIRCULATORY ENDOCARDITIS (INFLAMMATION SYSTEM OF THE INNER LAYER OF THE ****0714 M ACTIVE $196,273 $196,273 CANCER: FOLLICULAR (CLUSTERED NEOPLASMS INTO NODULES AND FOLLICLES) ****0780 F ACTIVE $180,366 $180,366 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****5385 M ACTIVE $178,630 $178,630 COMPLICATIONS OF CARDIAC AND INJURY, POISONING VASCULAR PROSTHETIC DEVICES, AND EXTERNAL IMPLANTS AND GRAFTS CAUSE OUTCOMES ****1401 F ACTIVE YES $176,040 $176,040 DERMATOPOLYMYOSITIS MUSCULOSKELETAL (INFLAMMATORY DISEASE OF AND CONNECTIVE MUSCLE AND SKIN) TISSUE ****6306 F CANCEL YES $171,959 $171,959 SYSTEMIC LUPUS ERYTHEMATOSUS MUSCULOSKELETAL (CHRONIC CONNECTIVE TISSUE AND CONNECTIVE DISEASE) TISSUE ****2836 F ACTIVE $170,608 $170,608 RHEUMATIC MITRAL VALVE CIRCULATORY DISEASES SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 3 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****3037 F ACTIVE $167,285 $167,285 PARALYTIC ILEUS AND INTESTINAL DIGESTIVE SYSTEM OBSTRUCTION WITHOUT HERNIA ****3163 F ACTIVE YES $166,112 $166,112 CANCER: TONGUE, OTHER AND NEOPLASMS UNSPECIFIED ****8872 M CANCEL YES $162,822 $162,822 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****1301 F ACTIVE $158,965 $158,965 CANCER: BREAST NEOPLASMS

****1455 F ACTIVE YES $157,938 $157,938 CANCER: PAROTID SALIVARY NEOPLASMS GLAND ****2236 F ACTIVE YES $157,443 $157,443 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****5379 F ACTIVE $155,602 $155,602 IMMUNODEFICIENCY: BLOOD AND CERTAIN SARCOIDOSIS (FORMATION OF IMMUNE DISORDERS LESIONS) ****0634 F ACTIVE $150,906 $150,906 ULCERATIVE COLITIS DIGESTIVE SYSTEM

****2742 F ACTIVE $150,766 $150,766 OTHER NECROTIZING MUSCULOSKELETAL VASCULOPATHIES (BLOOD VESSEL AND CONNECTIVE INFLAMMATION) TISSUE ****4784 M ACTIVE $139,864 $139,864 OTHER SPONDYLOPATHIES MUSCULOSKELETAL (VERTEBRAE DISORDERS) AND CONNECTIVE TISSUE ****6610 M ACTIVE YES $139,494 $139,494 NEWBORN RESPIRATORY PERINATAL DISTRESS CONDITIONS ****5819 M CANCEL YES $139,338 $139,338 HYPERTENSIVE HEART AND CIRCULATORY CHRONIC KIDNEY DISEASE SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 4 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****5785 F ACTIVE YES $138,497 $138,497 CANCER: COLON NEOPLASMS

****9889 M CANCEL YES $138,119 $138,119 OTHER SEPSIS (BLOOD INFECTIOUS AND INFECTIONS) PARASITIC ****8588 F ACTIVE YES $137,218 $137,218 DIVERTICULAR DISEASE OF THE DIGESTIVE SYSTEM INTESTINE ****7867 F ACTIVE YES $134,994 $134,994 LIVEBORN INFANTS ACCORDING FACTORS TO PLACE OR BIRTH AND TYPE OF INFLUENCING HEALTH DELIVERY ****9789 M ACTIVE $134,090 $134,090 CANCER: COLON NEOPLASMS

****8888 M ACTIVE $127,969 $127,969 MULTIPLE SCLEROSIS NERVOUS SYSTEM

****8728 F ACTIVE YES $122,901 $122,901 OTHER BACTERIAL INTESTINAL INFECTIOUS AND INFECTIONS PARASITIC ****7147 F CANCEL YES $122,216 $122,216 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****9693 F CANCEL YES $118,281 $118,281 OTHER SEPSIS (BLOOD INFECTIOUS AND INFECTIONS) PARASITIC ****4864 M ACTIVE $118,119 $118,119 OTHER VENOUS EMBOLISM AND CIRCULATORY THROMBOSIS (BLOOD CLOT) SYSTEM ****7951 F ACTIVE YES $118,111 $118,111 OTHER DISORDERS OF THE BRAIN NERVOUS SYSTEM

****1075 M ACTIVE $117,263 $117,263 OSTEOARTHRITIS: HIP MUSCULOSKELETAL AND CONNECTIVE TISSUE

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 5 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****4818 F ACTIVE YES $115,726 $115,726 DISEASES OF THE SOFT TISSUE DIGESTIVE SYSTEM STRUCTURES OF THE MOUTH ****2736 M ACTIVE $113,444 $113,444 OTHER SEPSIS (BLOOD INFECTIOUS AND INFECTIONS) PARASITIC ****7847 M ACTIVE $112,374 $112,374 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****0234 M ACTIVE $110,079 $110,079 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****0360 M ACTIVE $106,386 $106,386 OTHER SPONDYLOPATHIES MUSCULOSKELETAL (VERTEBRAE DISORDERS) AND CONNECTIVE TISSUE ****8008 M ACTIVE $105,855 $105,855 BURN AND CORROSION OF ANKLE INJURY, POISONING AND FOOT AND EXTERNAL CAUSE OUTCOMES ****3143 F ACTIVE $104,009 $104,009 PERSONAL HISTORY OF FACTORS MALIGNANT NEOPLASM (CANCER) INFLUENCING HEALTH ****0720 M CANCEL YES $100,928 $100,928 CANCER: OROPHARYNX, BACK OF NEOPLASMS MOUTH ****2162 F ACTIVE $99,406 $99,406 MULTIPLE SCLEROSIS NERVOUS SYSTEM

****6566 M ACTIVE $97,454 $97,454 COMPLICATIONS AND ILL DEFINED CIRCULATORY DESCRIPTIONS OF HEART DISEASE SYSTEM ****5965 M ACTIVE $97,036 $97,036 LIVEBORN INFANTS ACCORDING FACTORS TO PLACE OR BIRTH AND TYPE OF INFLUENCING HEALTH DELIVERY ****6190 F ACTIVE $95,580 $95,580 DORSALGIA (BACK PAIN) MUSCULOSKELETAL AND CONNECTIVE TISSUE

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 6 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****5139 F ACTIVE $93,554 $93,554 CROHN'S DISEASE (REGIONAL DIGESTIVE SYSTEM ENTERITIS) ****4258 F ACTIVE YES $92,358 $92,358 RESPIRATORY FAILURE NOT RESPIRATORY ELSEWHERE CLASSIFIED SYSTEM ****5079 M ACTIVE $91,538 $91,538 FRACTURE OF FEMUR INJURY, POISONING AND EXTERNAL CAUSE OUTCOMES ****8552 M ACTIVE $91,513 $91,513 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****7371 F CANCEL $91,399 $91,399 RENAL FAILURE: ACUTE GENITOURINARY SYSTEM ****6130 F ACTIVE $91,037 $91,037 NONRHEUMATIC AORTIC VALVE CIRCULATORY DISORDERS SYSTEM ****6610 M ACTIVE YES $89,790 $89,790 LIVEBORN INFANTS ACCORDING FACTORS TO PLACE OR BIRTH AND TYPE OF INFLUENCING HEALTH DELIVERY ****1615 M ACTIVE $89,462 $89,462 OTHER SPONDYLOPATHIES MUSCULOSKELETAL (VERTEBRAE DISORDERS) AND CONNECTIVE TISSUE ****5939 M CANCEL $89,314 $89,314 FRACTURE OF LOWER LEG INJURY, POISONING INCLUDING ANKLE AND EXTERNAL CAUSE OUTCOMES ****4104 M ACTIVE $88,421 $88,421 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****6166 F ACTIVE YES $87,990 $87,990 CARDIOMYOPATHY (HEART CIRCULATORY MUSCLE DISEASE) SYSTEM ****8988 M ACTIVE YES $87,373 $87,373 FRACTURE OF LUMBAR SPINE AND INJURY, POISONING PELVIS AND EXTERNAL CAUSE OUTCOMES

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 7 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****2082 F ACTIVE $84,152 $84,152 CROHN'S DISEASE (REGIONAL DIGESTIVE SYSTEM ENTERITIS) ****4278 M CANCEL $83,279 $83,279 OTHER DEFORMING MUSCULOSKELETAL DORSOPATHIES (BACK AND SPINE AND CONNECTIVE DISEASES) TISSUE ****1761 F ACTIVE $83,101 $83,101 ENCOUNTER FOR ATTENTION TO FACTORS ARTIFICIAL OPENINGS INFLUENCING HEALTH ****1541 M ACTIVE $82,846 $82,846 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****9389 F ACTIVE YES $82,744 $82,744 CANCER: LUNG AND BRONCHUS NEOPLASMS

****4844 M ACTIVE $78,994 $78,994 OSTEOARTHRITIS: KNEE MUSCULOSKELETAL AND CONNECTIVE TISSUE ****5725 F ACTIVE $78,092 $78,092 BENIGN NEOPLASMS: MENINGES NEOPLASMS (BRAIN AND SPINAL CORD CONNECTIVE TISSUE) ****0234 F ACTIVE YES $74,138 $74,138 OTHER NECROTIZING MUSCULOSKELETAL VASCULOPATHIES (BLOOD VESSEL AND CONNECTIVE INFLAMMATION) TISSUE ****8692 F ACTIVE $73,884 $73,884 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****7987 M ACTIVE $73,854 $73,854 DIVERTICULAR DISEASE OF THE DIGESTIVE SYSTEM INTESTINE ****9369 F ACTIVE $72,308 $72,308 CANCER: LUNG AND BRONCHUS NEOPLASMS

****1175 M ACTIVE $72,250 $72,250 CROHN'S DISEASE (REGIONAL DIGESTIVE SYSTEM ENTERITIS)

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 8 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****1201 F ACTIVE $71,607 $71,607 OSTEOARTHRITIS: HIP MUSCULOSKELETAL AND CONNECTIVE TISSUE ****8952 F ACTIVE $71,596 $71,596 PAIN IN THROAT AND CHEST SYMPTOMS, SIGNS, AND ABNORMAL FINDINGS ****4964 F ACTIVE $71,459 $71,459 ATRIAL FIBRILLATION AND CIRCULATORY FLUTTER (IRREGULAR AND RAPID SYSTEM HEART RHYTHM) ****2596 F ACTIVE $70,882 $70,882 RHEUMATOID ARTHRITIS WITH MUSCULOSKELETAL RHEUMATOID FACTOR AND CONNECTIVE TISSUE ****6166 M ACTIVE YES $70,309 $70,309 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****0054 M CANCEL $70,016 $70,016 INTRACRANIAL INJURY INJURY, POISONING AND EXTERNAL CAUSE OUTCOMES ****6586 F ACTIVE $69,160 $69,160 OTHER SPONDYLOPATHIES MUSCULOSKELETAL (VERTEBRAE DISORDERS) AND CONNECTIVE TISSUE ****3483 F ACTIVE $68,916 $68,916 COMPLICATIONS OF INTERNAL INJURY, POISONING ORTHOPEDIC PROSTHETIC AND EXTERNAL DEVICES, IMPLANTS AND GRAFTS CAUSE OUTCOMES ****6326 F CANCEL $68,495 $68,495 OSTEOARTHRITIS: KNEE MUSCULOSKELETAL AND CONNECTIVE TISSUE ****7727 M ACTIVE $68,375 $68,375 CARDIOMYOPATHY (HEART CIRCULATORY MUSCLE DISEASE) SYSTEM ****9289 M ACTIVE $68,298 $68,298 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****1375 F ACTIVE YES $67,875 $67,875 MAJOR DEPRESSIVE DISORDER, MENTAL AND SINGLE EPISODE BEHAVIORAL DISORDERS

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 9 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****4504 M ACTIVE $67,142 $67,142 FRACTURE OF FEMUR INJURY, POISONING AND EXTERNAL CAUSE OUTCOMES ****2642 F ACTIVE $67,048 $67,048 PAROXYSMAL TACHYCARDIA CIRCULATORY (RAPID HEART BEAT) SYSTEM ****9789 F ACTIVE $66,651 $66,651 BENIGN NEOPLASMS: MENINGES NEOPLASMS (BRAIN AND SPINAL CORD CONNECTIVE TISSUE) ****9313 M ACTIVE $66,239 $66,239 OTHER CHRONIC OBSTRUCTIVE RESPIRATORY PULMONARY DISEASE (COPD) SYSTEM ****4078 M ACTIVE $65,766 $65,766 CANCER: LIVER AND BILE DUCTS NEOPLASMS

****0920 F ACTIVE $63,860 $63,860 OVERWEIGHT AND OBESITY ENDOCRINE, NUTRITIONAL AND METABOLIC ****3017 F ACTIVE YES $63,690 $63,690 ABNORMALITIES OF HEART BEAT SYMPTOMS, SIGNS, AND ABNORMAL FINDINGS ****3583 F ACTIVE $63,427 $63,427 COMPLICATIONS OF INTERNAL INJURY, POISONING ORTHOPEDIC PROSTHETIC AND EXTERNAL DEVICES, IMPLANTS AND GRAFTS CAUSE OUTCOMES ****9209 M ACTIVE $62,676 $62,676 INTRACRANIAL INJURY INJURY, POISONING AND EXTERNAL CAUSE OUTCOMES ****8728 M ACTIVE YES $61,693 $61,693 ATRIAL FIBRILLATION AND CIRCULATORY FLUTTER (IRREGULAR AND RAPID SYSTEM HEART RHYTHM) ****3823 M ACTIVE $61,310 $61,310 ALCOHOL RELATED DISORDERS MENTAL AND BEHAVIORAL DISORDERS ****6966 F ACTIVE $61,004 $61,004 RENAL FAILURE: ACUTE GENITOURINARY SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 10 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****2656 M ACTIVE $60,447 $60,447 OTHER DISEASES OF THE DIGESTIVE SYSTEM GALLBLADDER ****0580 M ACTIVE YES $59,809 $59,809 CYSTITIS GENITOURINARY (INFLAMMATION/INFECTION OF SYSTEM THE URINARY TRACT) ****6230 M ACTIVE $59,723 $59,723 OSTEOARTHRITIS: HIP MUSCULOSKELETAL AND CONNECTIVE TISSUE ****0314 M ACTIVE $59,616 $59,616 OSTEONECROSIS (DESTRUCTION MUSCULOSKELETAL OF BONE TISSUE) AND CONNECTIVE TISSUE ****6066 M ACTIVE $59,102 $59,102 CANCER: PROSTATE NEOPLASMS

****8408 F CANCEL $59,077 $59,077 MULTIPLE SCLEROSIS NERVOUS SYSTEM

****4164 M ACTIVE $58,547 $58,547 DIVERTICULAR DISEASE OF THE DIGESTIVE SYSTEM INTESTINE ****9693 F ACTIVE $58,131 $58,131 OTHER SPONDYLOPATHIES MUSCULOSKELETAL (VERTEBRAE DISORDERS) AND CONNECTIVE TISSUE ****1541 M ACTIVE $57,455 $57,455 COMPLICATIONS OF BARIATRIC DIGESTIVE SYSTEM PROCEDURES ****9049 M ACTIVE $56,860 $56,860 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****1481 M CANCEL $56,232 $56,232 RENAL FAILURE: ACUTE GENITOURINARY SYSTEM ****5359 M ACTIVE $53,520 $53,520 CHRONIC SINUSITIS RESPIRATORY SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2017 through DEC 2017 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:45:38AM Page 11 of 11 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****4798 M ACTIVE $52,968 $52,968 PARALYTIC ILEUS AND INTESTINAL DIGESTIVE SYSTEM OBSTRUCTION WITHOUT HERNIA ****8868 M ACTIVE $52,913 $52,913 CANCER: KIDNEY NEOPLASMS

****4838 M ACTIVE $52,702 $52,702 OSTEOARTHRITIS: KNEE MUSCULOSKELETAL AND CONNECTIVE TISSUE ****1235 F ACTIVE YES $52,566 $52,566 RESPIRATORY FAILURE NOT RESPIRATORY ELSEWHERE CLASSIFIED SYSTEM ****6766 F ACTIVE $52,554 $52,554 DISLOCATION AND SPRAIN OF INJURY, POISONING JOINTS AND LIGAMENTS OF KNEE AND EXTERNAL CAUSE OUTCOMES ****0054 M CANCEL $52,542 $52,542 NONTRAUMATIC INTRACEREBRAL CIRCULATORY HEMORRHAGE ( BLEEDING IN THE SYSTEM BRAIN) ****9929 F ACTIVE $52,517 $52,517 IMMUNODEFICIENCY: COMMON BLOOD AND CERTAIN VARIABLE IMMUNE DISORDERS ****9133 M ACTIVE $52,104 $52,104 CANCER: PROSTATE NEOPLASMS

****8248 F ACTIVE $51,650 $51,650 ESSENTIAL (PRIMARY) CIRCULATORY HYPERTENSION SYSTEM ****2742 M ACTIVE $51,288 $51,288 CANCER: PROSTATE NEOPLASMS

****1495 M ACTIVE $51,203 $51,203 EPILEPSY AND RECURRENT NERVOUS SYSTEM SEIZURES ****3003 M ACTIVE $50,269 $50,269 OTHER DISORDERS OF VEINS CIRCULATORY SYSTEM

Grand Total : $16,412,798 $16,412,798

*A "YES" in the "Referred to Case Mgmt" column may not indicate enrollment in a Case Management program. RTOR0902 Client Reference#: 023040000008 CLAIMS SUMMARY : LAG

Paid : JAN 2017 through DEC 2017 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:42:45AM Page 1 of 4

ALL LINES OF BUSINESS

PAID INCURRED Jan - 2017 Feb - 2017 Mar - 2017 Apr - 2017 May - 2017 Jun - 2017 Jul - 2017 Aug - 2017 Sep - 2017 Oct - 2017 Nov - 2017 Dec - 2017 Total Apr - 2014 0 413 204 0 0 0 0 0 0 0 0 0 618 May - 2014 0 62 0 0 0 0 0 0 0 0 30 0 93 Jun - 2014 0 0 0 0 0 77 0 0 0 10 0 0 87 Jul - 2014 0 11 0 0 0 0 8 0 0 0 51 0 70 Aug - 2014 0 11 0 0 0 0 68 0 0 0 0 0 78 Sep - 2014 0 587 0 0 0 0 14 0 0 0 52 0 654 Oct - 2014 0 60 -266 0 0 0 0 0 115 0 0 0 -91 Nov - 2014 0 14 15 -81 0 46 0 0 0 0 0 52 46 Dec - 2014 0 38 0 0 0 -11 0 -61 0 0 61 0 28 Jan - 2015 28 0 189 -177 -11 0 0 439 0 0 15 0 483 Feb - 2015 120 -358 570 0 0 0 0 0 0 0 15 30 377 Mar - 2015 193 -6,470 6,637 0 -562 32 0 0 -47 0 15 65 -137 Apr - 2015 9,107 135 -1,000 0 0 0 0 0 0 0 290 26 8,558 May - 2015 8,844 173 -397 0 0 0 0 0 0 0 43 117 8,779 Jun - 2015 8,897 210 269 0 -11 0 0 0 23 0 2 15,581 24,972 Jul - 2015 31 11,690 293 0 0 0 28 0 0 0 168 241 12,451 Aug - 2015 110 8,699 72 49 0 30 -352 0 0 -135 393 0 8,866 Sep - 2015 1,792 6 522 0 0 0 -649 0 0 0 0 -195 1,476 Oct - 2015 7,840 777 78 23,022 0 103 0 0 0 0 0 0 31,821 Nov - 2015 17,251 441 333 617 -9 402 94 0 0 -2,414 0 0 16,715 Dec - 2015 518 563 586 596 9,918 919 0 0 0 -7,403 2,580 58 8,335 Jan - 2016 722 -6,119 19,217 3,215 317 730 0 0 -81 0 0 -116 17,884 Feb - 2016 9,475 7,276 3,092 2,648 1,338 739 2,154 -1,682 -47 0 0 0 24,993 Mar - 2016 -1,144 -5,416 19,930 25,696 912 598 53 0 1,202 2,766 -8,723 -101 35,773 Apr - 2016 11,605 11,141 14,392 7,789 866 428 0 83 586 353 0 -1,739 45,505 May - 2016 -4,753 3,220 44,425 21,695 20,484 875 2,068 15 878 361 -7,460 -674 81,133 Jun - 2016 14,317 17,807 38,149 66,807 67,376 -14,059 1,405 5,625 -34,488 1,218 0 228 164,384 Jul - 2016 13,286 10,529 14,404 4,941 10,929 4,429 2,050 2,325 -5,991 556 64 -205 57,318 Aug - 2016 28,252 21,046 99,132 9,148 28,002 11,252 3,019 -415 4,706 -1,775 475 21,859 224,701 Sep - 2016 24,806 175,710 28,227 27,660 -4,710 3,911 14,744 13,371 1,144 -1,227 1,629 3,119 288,383 Oct - 2016 68,571 53,052 76,992 37,271 133,081 20,955 5,234 2,597 -1,226 1,865 465 3,189 402,046 Nov - 2016 488,337 160,017 35,232 24,399 45,913 -41,680 4,180 2,811 5,812 79,998 3,199 1,746 809,964 HMO payment information includes fee-for-service claims only. No deductible referrals or priced encounters are included. RTOR0301 Client Reference#: 023040000008 CLAIMS SUMMARY : LAG

Paid : JAN 2017 through DEC 2017 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:42:45AM Page 2 of 4 Jan - 2017 Feb - 2017 Mar - 2017 Apr - 2017 May - 2017 Jun - 2017 Jul - 2017 Aug - 2017 Sep - 2017 Oct - 2017 Nov - 2017 Dec - 2017 Total Dec - 2016 1,788,875 232,208 49,893 62,834 48,465 29,468 18,744 2,108 4,639 13,285 14,554 1,277 2,266,350 Jan - 2017 748,647 1,959,754 892,513 134,357 49,654 21,292 49,468 40,477 1,426 4,270 18,165 20,075 3,940,096 Feb - 2017 0 901,332 2,209,418 435,512 93,744 68,789 29,982 19,604 5,593 6,545 11,973 9,906 3,792,397 Mar - 2017 0 0 1,256,274 1,766,144 741,236 173,640 22,233 10,905 20,337 16,713 15,910 25,485 4,048,877 Apr - 2017 0 0 0 857,003 1,839,680 507,984 530,766 17,159 159,996 25,166 22,454 21,630 3,981,838 May - 2017 0 0 0 0 994,625 2,042,162 429,966 131,825 154,865 13,695 43,012 87,850 3,898,000 Jun - 2017 0 0 0 0 0 934,380 2,032,833 537,200 90,226 58,446 58,466 60,103 3,771,654 Jul - 2017 0 0 0 0 0 0 815,130 1,820,644 555,254 163,549 29,442 40,995 3,425,014 Aug - 2017 0 0 0 0 0 0 0 917,225 2,236,536 386,727 155,358 41,636 3,737,483 Sep - 2017 0 0 0 0 0 0 0 0 910,188 1,992,436 660,065 147,755 3,710,444 Oct - 2017 0 0 0 0 0 0 0 0 0 976,651 1,705,828 318,920 3,001,400 Nov - 2017 0 0 0 0 0 0 0 0 0 0 1,044,082 1,634,052 2,678,135 Dec - 2017 0 0 0 0 0 0 0 0 0 0 0 885,409 885,409 Total : 3,245,728 3,558,618 4,809,395 3,511,142 4,081,238 3,767,494 3,963,240 3,522,254 4,111,647 3,731,654 3,772,675 3,338,372 45,413,456

HMO payment information includes fee-for-service claims only. No deductible referrals or priced encounters are included. RTOR0301 Client Reference#: 023040000008 CLAIMS SUMMARY : LAG

Paid : JAN 2017 through DEC 2017 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:42:45AM Page 3 of 4

COMPREHENSIVE MAJOR MEDICAL

HMO payment information includes fee-for-service claims only. No deductible referrals or priced encounters are included. RTOR0301 Client Reference#: 023040000008 CLAIMS SUMMARY : LAG

Paid : JAN 2017 through DEC 2017 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/19/2018 9:42:45AM Page 4 of 4 Jan - 2017 Feb - 2017 Mar - 2017 Apr - 2017 May - 2017 Jun - 2017 Jul - 2017 Aug - 2017 Sep - 2017 Oct - 2017 Nov - 2017 Dec - 2017 Total

Nov - 2016 488,337 160,017 35,232 24,399 45,913 -41,680 4,180 2,811 5,812 79,998 3,199 1,746 809,964 Dec - 2016 1,788,875 232,208 49,893 62,834 48,465 29,468 18,744 2,108 4,639 13,285 14,554 1,277 2,266,350 Jan - 2017 748,647 1,959,754 892,513 134,357 49,654 21,292 49,468 40,477 1,426 4,270 18,165 20,075 3,940,096 Feb - 2017 0 901,332 2,209,418 435,512 93,744 68,789 29,982 19,604 5,593 6,545 11,973 9,906 3,792,397 Mar - 2017 0 0 1,256,274 1,766,144 741,236 173,640 22,233 10,905 20,337 16,713 15,910 25,485 4,048,877 Apr - 2017 0 0 0 857,003 1,839,680 507,984 530,766 17,159 159,996 25,166 22,454 21,630 3,981,838 May - 2017 0 0 0 0 994,625 2,042,162 429,966 131,825 154,865 13,695 43,012 87,850 3,898,000 Jun - 2017 0 0 0 0 0 934,380 2,032,833 537,200 90,226 58,446 58,466 60,103 3,771,654 Jul - 2017 0 0 0 0 0 0 815,130 1,820,644 555,254 163,549 29,442 40,995 3,425,014 Aug - 2017 0 0 0 0 0 0 0 917,225 2,236,536 386,727 155,358 41,636 3,737,483 Sep - 2017 0 0 0 0 0 0 0 0 910,188 1,992,436 660,065 147,755 3,710,444 Oct - 2017 0 0 0 0 0 0 0 0 0 976,651 1,705,828 318,920 3,001,400 Nov - 2017 0 0 0 0 0 0 0 0 0 0 1,044,082 1,634,052 2,678,135 Dec - 2017 0 0 0 0 0 0 0 0 0 0 0 885,409 885,409 Total : 3,245,728 3,558,618 4,809,395 3,511,142 4,081,238 3,767,494 3,963,240 3,522,254 4,111,647 3,731,654 3,772,675 3,338,372 45,413,456

HMO payment information includes fee-for-service claims only. No deductible referrals or priced encounters are included. RTOR0301 Client Reference#: 023040000008 CLAIMS SUMMARY : Payments by Line of Business - Summary All Sections

Report Type : Total Paid Claims - All Sections - Medical Mutual and Employer Paid Claims Combined

Paid : JAN 2018 through DEC 2018 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:37:46PM Page 1 of 1

SUMMARY LINK TO : CHART ALL SECTIONS Jan - 2018 Feb - 2018 Mar - 2018 Apr - 2018 May - 2018 Jun - 2018 Jul - 2018 Aug - 2018 Sep - 2018 Oct - 2018 Nov - 2018 Dec - 2018 Total

Comp. Major 3,764,321 4,507,201 4,622,211 3,638,869 4,341,917 4,068,824 3,996,709 4,510,790 3,862,325 4,735,452 4,283,582 4,187,924 50,520,127 Medical

Total 3,764,321 4,507,201 4,622,211 3,638,869 4,341,917 4,068,824 3,996,709 4,510,790 3,862,325 4,735,452 4,283,582 4,187,924 50,520,127

Date Range : JAN 2018 through DEC 2018

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:39:06PM Page 1 of 1 COMP MAJOR MEDICAL

2 Person : 2 Person : Employee 3 Person : Total Total Month Year Single Emp/Spouse Emp/Child Family /Children Emp/Sp/Child Medifil Contracts Members January 2018 1,610 0 0 2,834 0 0 0 4,444 11,130 February 2018 1,612 0 0 2,846 0 0 0 4,458 11,172 March 2018 1,636 0 0 2,836 0 0 0 4,472 11,167 April 2018 1,662 0 0 2,781 0 0 0 4,443 11,002 May 2018 1,657 0 0 2,773 0 0 0 4,430 10,971 June 2018 1,650 0 0 2,757 0 0 0 4,407 10,915 July 2018 1,632 0 0 2,726 0 0 0 4,358 10,795 August 2018 1,651 0 0 2,720 0 0 0 4,371 10,785 September 2018 1,653 0 0 2,722 0 0 0 4,375 10,752 October 2018 1,651 0 0 2,711 0 0 0 4,362 10,728 November 2018 1,652 0 0 2,711 0 0 0 4,363 10,717 December 2018 1,685 0 0 2,718 0 0 0 4,403 10,746 Total : 19,751 0 0 33,135 0 0 0 52,886 130,880 Average : 1,646 0 0 2,761 0 0 0 4,407 10,907

RTOR0403 Client Reference#: 023040000008 CLAIMS SUMMARY : LAG

Paid : JAN 2018 through DEC 2018 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:38:33PM Page 1 of 4

ALL LINES OF BUSINESS

PAID INCURRED Jan - 2018 Feb - 2018 Mar - 2018 Apr - 2018 May - 2018 Jun - 2018 Jul - 2018 Aug - 2018 Sep - 2018 Oct - 2018 Nov - 2018 Dec - 2018 Total Jul - 2014 0 0 0 0 0 0 0 0 0 43 0 0 43 Oct - 2014 0 700 0 0 0 0 0 0 0 0 0 1,388 2,088 Nov - 2014 0 0 0 0 0 0 0 0 0 0 0 21 21 Mar - 2015 22 0 0 0 0 0 0 0 0 32 0 0 55 Apr - 2015 52 0 16 0 0 0 0 0 0 52 0 0 120 May - 2015 0 0 55 0 0 59 0 0 0 0 0 0 114 Jun - 2015 0 52 0 0 0 0 0 0 0 0 0 0 52 Jul - 2015 0 0 36 129 0 15 0 0 0 0 0 0 180 Aug - 2015 0 0 0 0 0 8 0 0 0 18 0 0 26 Oct - 2015 0 31 0 0 0 0 0 0 11 0 0 0 41 Nov - 2015 -59 101 0 0 0 0 0 21 14 0 0 0 77 Dec - 2015 0 0 87 0 0 0 0 0 109 310 0 0 506 Jan - 2016 0 460 0 0 0 0 0 70 0 0 36 44 609 Feb - 2016 0 -210 0 0 0 0 -127 -266 0 19 0 0 -584 Mar - 2016 2,556 400 0 0 0 0 -24 0 0 0 0 89 3,021 Apr - 2016 -547 870 45 22 0 0 -594 0 106 0 0 79 -20 May - 2016 100 1,179 2,581 23 -197 0 0 0 0 596 0 0 4,282 Jun - 2016 491 3,143 -448 0 -32 617 -32 0 0 9 175 66 3,989 Jul - 2016 10,377 2,181 1,161 1,003 54 -44 -10,938 -80 0 371 0 0 4,086 Aug - 2016 -198 441 -690 0 347 -95 -2,694 -67 0 -40 0 0 -2,996 Sep - 2016 3,266 1,113 1,415 7 -57 613 0 144 -37 74 0 17 6,554 Oct - 2016 820 2,697 1,720 -3,082 710 0 -145 0 0 0 581 39 3,341 Nov - 2016 952 2,967 87 -1,012 -39 0 1,997 0 2 118 0 0 5,074 Dec - 2016 3,845 845 -194 -1,257 172 0 0 425 0 0 0 0 3,836 Jan - 2017 3,048 4,686 2,667 791 -3,426 -1,873 85 -107 657 326 2,622 -3,582 5,894 Feb - 2017 11,124 18,069 2,394 269 0 -1,989 2,083 65 159 0 0 0 32,172 Mar - 2017 8,671 8,610 -7,302 1,594 216 -413 -161 -392 -132 987 -90 6,726 18,314 Apr - 2017 3,447 13,425 9,011 4,086 1,567 2,835 1,135 34 1,841 898 828 399 39,506 May - 2017 68,535 22,773 16,232 14,871 25,613 -449 502 74 -1,565 -351 1,374 101 147,711 Jun - 2017 -12,376 18,275 13,617 9,763 14,797 62,751 2,225 79 -1,286 301 403 1,258 109,807 Jul - 2017 15,625 24,248 60,782 15,601 -48,384 4,680 2,159 14,766 -19 -44,961 1,280 -100 45,677 Aug - 2017 130,859 42,544 17,985 21,366 13,749 8,018 -3,581 495 -18 4,375 3,646 399 239,836 HMO payment information includes fee-for-service claims only. No deductible referrals or priced encounters are included. RTOR0301 Client Reference#: 023040000008 CLAIMS SUMMARY : LAG

Paid : JAN 2018 through DEC 2018 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:38:33PM Page 2 of 4 Jan - 2018 Feb - 2018 Mar - 2018 Apr - 2018 May - 2018 Jun - 2018 Jul - 2018 Aug - 2018 Sep - 2018 Oct - 2018 Nov - 2018 Dec - 2018 Total Sep - 2017 232,255 14,065 179,981 34,561 7,291 6,896 12,113 1,446 -10,048 15,908 4,221 -779 497,910 Oct - 2017 91,625 125,054 135,966 28,836 89,416 11,569 -36,958 34,273 -2,891 10,043 -2,145 205 484,994 Nov - 2017 536,097 153,553 94,439 17,762 38,130 14,221 -18,330 49,584 1,808 9,100 2,784 2,816 901,966 Dec - 2017 1,649,117 510,031 164,950 46,900 26,844 19,829 15,174 21,616 384 26,317 14,313 6,393 2,501,868 Jan - 2018 1,004,616 2,452,124 388,007 145,860 161,702 20,354 18,314 -870 13,880 30,489 3,081 1,851 4,239,409 Feb - 2018 0 1,082,774 1,967,263 448,267 201,937 89,982 44,980 37,130 265,833 55,113 33,833 -20,827 4,206,287 Mar - 2018 0 0 1,570,349 1,886,080 846,093 366,509 284,525 18,610 17,378 313,858 21,229 5,970 5,330,601 Apr - 2018 0 0 0 966,428 1,870,319 612,234 254,717 101,226 19,616 58,072 13,107 21,741 3,917,461 May - 2018 0 0 0 0 1,095,096 1,765,056 567,397 274,522 100,549 64,081 140,192 51,335 4,058,229 Jun - 2018 0 0 0 0 0 1,087,442 1,968,774 591,028 105,082 187,601 154,785 53,954 4,148,666 Jul - 2018 0 0 0 0 0 0 894,114 2,305,559 378,120 180,974 152,591 92,834 4,004,192 Aug - 2018 0 0 0 0 0 0 0 1,061,405 2,165,886 544,792 300,469 146,620 4,219,171 Sep - 2018 0 0 0 0 0 0 0 0 806,884 2,000,482 413,155 258,478 3,478,999 Oct - 2018 0 0 0 0 0 0 0 0 0 1,275,443 1,915,454 516,739 3,707,636 Nov - 2018 0 0 0 0 0 0 0 0 0 0 1,105,656 2,080,510 3,186,167 Dec - 2018 0 0 0 0 0 0 0 0 0 0 0 963,137 963,137 Total : 3,764,321 4,507,201 4,622,211 3,638,869 4,341,917 4,068,824 3,996,709 4,510,790 3,862,325 4,735,452 4,283,582 4,187,924 50,520,127

HMO payment information includes fee-for-service claims only. No deductible referrals or priced encounters are included. RTOR0301 Client Reference#: 023040000008 CLAIMS SUMMARY : LAG

Paid : JAN 2018 through DEC 2018 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:38:33PM Page 3 of 4

COMP MAJOR MEDICAL

HMO payment information includes fee-for-service claims only. No deductible referrals or priced encounters are included. RTOR0301 Client Reference#: 023040000008 CLAIMS SUMMARY : LAG

Paid : JAN 2018 through DEC 2018 Incurred : ALL

CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:38:33PM Page 4 of 4 Jan - 2018 Feb - 2018 Mar - 2018 Apr - 2018 May - 2018 Jun - 2018 Jul - 2018 Aug - 2018 Sep - 2018 Oct - 2018 Nov - 2018 Dec - 2018 Total

Aug - 2017 130,859 42,544 17,985 21,366 13,749 8,018 -3,581 495 -18 4,375 3,646 399 239,836 Sep - 2017 232,255 14,065 179,981 34,561 7,291 6,896 12,113 1,446 -10,048 15,908 4,221 -779 497,910 Oct - 2017 91,625 125,054 135,966 28,836 89,416 11,569 -36,958 34,273 -2,891 10,043 -2,145 205 484,994 Nov - 2017 536,097 153,553 94,439 17,762 38,130 14,221 -18,330 49,584 1,808 9,100 2,784 2,816 901,966 Dec - 2017 1,649,117 510,031 164,950 46,900 26,844 19,829 15,174 21,616 384 26,317 14,313 6,393 2,501,868 Jan - 2018 1,004,616 2,452,124 388,007 145,860 161,702 20,354 18,314 -870 13,880 30,489 3,081 1,851 4,239,409 Feb - 2018 0 1,082,774 1,967,263 448,267 201,937 89,982 44,980 37,130 265,833 55,113 33,833 -20,827 4,206,287 Mar - 2018 0 0 1,570,349 1,886,080 846,093 366,509 284,525 18,610 17,378 313,858 21,229 5,970 5,330,601 Apr - 2018 0 0 0 966,428 1,870,319 612,234 254,717 101,226 19,616 58,072 13,107 21,741 3,917,461 May - 2018 0 0 0 0 1,095,096 1,765,056 567,397 274,522 100,549 64,081 140,192 51,335 4,058,229 Jun - 2018 0 0 0 0 0 1,087,442 1,968,774 591,028 105,082 187,601 154,785 53,954 4,148,666 Jul - 2018 0 0 0 0 0 0 894,114 2,305,559 378,120 180,974 152,591 92,834 4,004,192 Aug - 2018 0 0 0 0 0 0 0 1,061,405 2,165,886 544,792 300,469 146,620 4,219,171 Sep - 2018 0 0 0 0 0 0 0 0 806,884 2,000,482 413,155 258,478 3,478,999 Oct - 2018 0 0 0 0 0 0 0 0 0 1,275,443 1,915,454 516,739 3,707,636 Nov - 2018 0 0 0 0 0 0 0 0 0 0 1,105,656 2,080,510 3,186,167 Dec - 2018 0 0 0 0 0 0 0 0 0 0 0 963,137 963,137 Total : 3,764,321 4,507,201 4,622,211 3,638,869 4,341,917 4,068,824 3,996,709 4,510,790 3,862,325 4,735,452 4,283,582 4,187,924 50,520,127

HMO payment information includes fee-for-service claims only. No deductible referrals or priced encounters are included. RTOR0301 Client Reference#: 023040000008 CLAIMANT ANALYSIS : High Cost Claimant Summary Medical All - By Payments : $ 50,000 +

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 1 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****5139 F ACTIVE YES $924,380 $924,380 COMPLICATIONS PECULIAR TO INJURY, POISONING REATTACHMENT AND AMPUTATION AND EXTERNAL CAUSE OUTCOMES ****8032 M ACTIVE YES $540,249 $540,249 CANCER: RECTOSIGMOID NEOPLASMS

****1915 F ACTIVE YES $530,444 $530,444 CANCER: BREAST NEOPLASMS

****7331 M ACTIVE YES $473,647 $473,647 NONTRAUMATIC SUBARACHNOID CIRCULATORY HEMORRHAGE (BLEEDING IN THE SYSTEM AREAS SURROUNDING THE BRAIN) ****8928 F ACTIVE YES $471,651 $471,651 OTHER PULMONARY HEART CIRCULATORY DISEASES SYSTEM ****2236 F ACTIVE YES $418,716 $418,716 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****9289 M ACTIVE YES $417,609 $417,609 CANCER: MULTIPLE MYELOMA AND NEOPLASMS PLASMA CELL NEOPLASMS ****0414 M CANCEL YES $413,922 $413,922 HYPERTENSIVE HEART AND CIRCULATORY CHRONIC KIDNEY DISEASE SYSTEM ****2096 M ACTIVE YES $390,914 $390,914 CANCER: SECONDARY NEOPLASMS RESPIRATORY AND DIGESTIVE ORGANS ****2922 M ACTIVE YES $382,979 $382,979 HYPERTENSIVE HEART DISEASE CIRCULATORY SYSTEM ****8728 F ACTIVE YES $347,839 $347,839 OTHER SEPSIS (BLOOD INFECTIOUS AND INFECTIONS) PARASITIC ****0654 M ACTIVE YES $307,761 $307,761 NONRHEUMATIC AORTIC VALVE CIRCULATORY DISORDERS SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 2 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****9789 M ACTIVE YES $281,982 $281,982 CANCER: COLON NEOPLASMS

****2596 M ACTIVE YES $248,422 $248,422 BENIGN NEOPLASMS: BONE AND NEOPLASMS ARTICULAR CARTILAGE ****4798 M ACTIVE YES $240,207 $240,207 SYMPTOMS AND SIGNS SYMPTOMS, SIGNS, ASSOCIATED WITH SYSTEMIC AND ABNORMAL INFLAMMATION AND INFECTION FINDINGS ****0040 F ACTIVE YES $226,467 $226,467 CEREBRAL INFARCTION (STROKE, CIRCULATORY BLOOD CLOT, BLOCKAGE, ETC.) SYSTEM ****3383 M CANCEL YES $214,864 $214,864 OTHER CONGENITAL CONGENITAL MALFORMATION OF CIRCULATORY ABNORMALITIES SYSTEM ****4604 M ACTIVE YES $211,788 $211,788 CANCER: PANCREAS NEOPLASMS

****3103 M CANCEL YES $201,280 $201,280 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****9289 M ACTIVE YES $196,612 $196,612 MULTIPLE VALVE DISEASES CIRCULATORY SYSTEM ****5139 M ACTIVE YES $194,181 $194,181 CANCER: TONGUE, BASE NEOPLASMS

****0480 M CANCEL YES $192,710 $192,710 CHRONIC ISCHEMIC HEART CIRCULATORY DISEASE SYSTEM ****3777 M ACTIVE YES $189,180 $189,180 FRACTURE OF LOWER LEG INJURY, POISONING INCLUDING ANKLE AND EXTERNAL CAUSE OUTCOMES ****6610 M ACTIVE YES $180,506 $180,506 NEWBORN RESPIRATORY PERINATAL DISTRESS CONDITIONS

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 3 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****3503 M ACTIVE YES $179,191 $179,191 CANCER: STOMACH NEOPLASMS

****8812 M ACTIVE YES $176,776 $176,776 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****4798 F ACTIVE $175,757 $175,757 CANCER: BREAST NEOPLASMS

****2162 F ACTIVE $169,147 $169,147 MULTIPLE SCLEROSIS NERVOUS SYSTEM

****2742 F ACTIVE $169,133 $169,133 IMMUNODEFICIENCY: HEREDITARY BLOOD AND CERTAIN HYPOGAMMAGLOBULINEMIA (LOW IMMUNE DISORDERS GAMMA GLOBULIN) ****6950 F CANCEL YES $168,675 $168,675 CEREBRAL INFARCTION (STROKE, CIRCULATORY BLOOD CLOT, BLOCKAGE, ETC.) SYSTEM ****0294 M ACTIVE $164,695 $164,695 NONRHEUMATIC MITRAL VALVE CIRCULATORY DISORDERS SYSTEM ****3837 M ACTIVE YES $160,028 $160,028 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****3143 F ACTIVE $158,174 $158,174 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****3563 F ACTIVE $157,897 $157,897 SCOLIOSIS (CURVATURE OF THE MUSCULOSKELETAL SPINE) AND CONNECTIVE TISSUE ****2296 F ACTIVE $157,170 $157,170 CONVULSIONS NOT ELSEWHERE SYMPTOMS, SIGNS, CLASSIFIED AND ABNORMAL FINDINGS ****5379 F ACTIVE YES $156,291 $156,291 IMMUNODEFICIENCY: BLOOD AND CERTAIN SARCOIDOSIS (FORMATION OF IMMUNE DISORDERS LESIONS)

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 4 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****1915 F ACTIVE YES $150,206 $150,206 NEWBORN DISORDERS RELATED PERINATAL TO SHORT GESTATION AND LOW CONDITIONS BIRTH WEIGHT NOT ELSEWHERE ****8268 M ACTIVE $146,883 $146,883 INJURY OF INTRA-ABDOMINAL INJURY, POISONING ORGANS AND EXTERNAL CAUSE OUTCOMES ****8888 M ACTIVE $142,458 $142,458 MULTIPLE SCLEROSIS NERVOUS SYSTEM

****0274 M ACTIVE $137,472 $137,472 CHRONIC ISCHEMIC HEART CIRCULATORY DISEASE SYSTEM ****0714 M ACTIVE $136,997 $136,997 CANCER: FOLLICULAR (CLUSTERED NEOPLASMS INTO NODULES AND FOLLICLES) ****5665 F ACTIVE $131,043 $131,043 OTHER CARDIAC ARRHYTHMIAS CIRCULATORY (IRREGULAR HEART BEAT) SYSTEM ****0374 M CANCEL YES $130,317 $130,317 ACUTE PANCREATITIS DIGESTIVE SYSTEM

****0634 F ACTIVE $129,260 $129,260 ULCERATIVE COLITIS DIGESTIVE SYSTEM

****4258 F ACTIVE YES $125,446 $125,446 OTHER DISORDERS OF THE GENITOURINARY URINARY SYSTEM SYSTEM ****0074 M ACTIVE $123,634 $123,634 CANCER: FLOOR OF MOUTH NEOPLASMS

****8748 M ACTIVE YES $122,659 $122,659 EPILEPSY AND RECURRENT NERVOUS SYSTEM SEIZURES ****9513 F ACTIVE $120,897 $120,897 PUERPERAL (AFTER DELIVERY) PREGNANCY AND SEPSIS CHILDBIRTH

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 5 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****9409 F ACTIVE $120,106 $120,106 CARDIOMYOPATHY (HEART CIRCULATORY MUSCLE DISEASE) SYSTEM ****1235 M ACTIVE $118,083 $118,083 CANCER: PANCREAS NEOPLASMS

****8532 F ACTIVE $117,906 $117,906 OTHER VENOUS EMBOLISM AND CIRCULATORY THROMBOSIS (BLOOD CLOT) SYSTEM ****9389 F ACTIVE YES $115,819 $115,819 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****2862 M ACTIVE $115,287 $115,287 CROHN'S DISEASE (REGIONAL DIGESTIVE SYSTEM ENTERITIS) ****4044 F ACTIVE YES $110,952 $110,952 PAROXYSMAL TACHYCARDIA CIRCULATORY (RAPID HEART BEAT) SYSTEM ****4964 F ACTIVE $109,426 $109,426 RENAL FAILURE: ACUTE GENITOURINARY SYSTEM ****8292 F ACTIVE $107,689 $107,689 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****9929 M ACTIVE $106,025 $106,025 CHRONIC ISCHEMIC HEART CIRCULATORY DISEASE SYSTEM ****4818 F ACTIVE $105,947 $105,947 BENIGN NEOPLASMS: NEOPLASMS HEMANGIOMA AND LYMPHANGIOMA ****6526 M ACTIVE $105,761 $105,761 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****4458 M ACTIVE $105,284 $105,284 CANCER: TONSIL NEOPLASMS

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 6 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****1475 F ACTIVE $104,547 $104,547 OTHER CARDIAC ARRHYTHMIAS CIRCULATORY (IRREGULAR HEART BEAT) SYSTEM ****7847 M ACTIVE $103,098 $103,098 RENAL FAILURE: CHRONIC GENITOURINARY SYSTEM ****2816 F ACTIVE $102,282 $102,282 CANCER: BREAST NEOPLASMS

****1375 F ACTIVE YES $98,039 $98,039 MAJOR DEPRESSIVE DISORDER, MENTAL AND RECURRENT BEHAVIORAL DISORDERS ****4478 F ACTIVE $97,420 $97,420 SCOLIOSIS (CURVATURE OF THE MUSCULOSKELETAL SPINE) AND CONNECTIVE TISSUE ****4204 F ACTIVE YES $97,286 $97,286 PNEUMONIA, UNSPECIFIED RESPIRATORY ORGANISM SYSTEM ****2596 F ACTIVE $96,426 $96,426 RHEUMATOID ARTHRITIS WITH MUSCULOSKELETAL RHEUMATOID FACTOR AND CONNECTIVE TISSUE ****3217 M ACTIVE YES $96,045 $96,045 OTHER DISEASES OF THE DIGESTIVE SYSTEM PANCREAS ****9993 M CANCEL YES $95,010 $95,010 CANCER: SECONDARY OTHER AND NEOPLASMS UNSPECIFIED SITES ****2856 M ACTIVE $94,129 $94,129 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****6586 F ACTIVE $93,776 $93,776 PLEURAL EFFUSION (EXCESS FLUID RESPIRATORY SURROUNDING THE LUNGS) SYSTEM ****2702 M CANCEL YES $92,846 $92,846 HYPERTENSIVE HEART DISEASE CIRCULATORY SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 7 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****8728 M ACTIVE $91,114 $91,114 ATRIAL FIBRILLATION AND CIRCULATORY FLUTTER (IRREGULAR AND RAPID SYSTEM HEART RHYTHM) ****3317 M ACTIVE $90,881 $90,881 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****8548 M ACTIVE $89,891 $89,891 FRACTURE OF FEMUR INJURY, POISONING AND EXTERNAL CAUSE OUTCOMES ****7011 F ACTIVE YES $89,792 $89,792 ESSENTIAL (PRIMARY) CIRCULATORY HYPERTENSION SYSTEM ****1175 M ACTIVE $89,333 $89,333 CROHN'S DISEASE (REGIONAL DIGESTIVE SYSTEM ENTERITIS) ****7471 F ACTIVE $85,988 $85,988 SPONDYLOSIS (DEGENERATIVE MUSCULOSKELETAL OSTEOARTHRITIS OF THE SPINE) AND CONNECTIVE TISSUE ****9693 F ACTIVE $85,504 $85,504 POSTSURGICAL COMPLICATIONS MUSCULOSKELETAL AND MUSCULOSKELETAL AND CONNECTIVE DISORDERS NOT ELSEWHERE TISSUE ****8932 M ACTIVE $84,295 $84,295 DIABETES: TYPE 2 ENDOCRINE, NUTRITIONAL AND METABOLIC ****1755 F ACTIVE $83,213 $83,213 CANCER: CONNECTIVE AND SOFT NEOPLASMS TISSUE ****6966 F ACTIVE YES $82,891 $82,891 HYPERTENSIVE HEART AND CIRCULATORY CHRONIC KIDNEY DISEASE SYSTEM ****2136 F ACTIVE $81,677 $81,677 OTHER ANEURYSMS CIRCULATORY SYSTEM ****2916 M ACTIVE YES $81,351 $81,351 OTHER CEREBROVASCULAR CIRCULATORY DISEASES SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 8 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****9509 F ACTIVE $81,110 $81,110 CANCER: ANUS NEOPLASMS

****5799 M ACTIVE $80,976 $80,976 SEQUELAE (RESULT) OF CIRCULATORY CEREBROVASCULAR DISEASE SYSTEM ****2456 M ACTIVE YES $80,726 $80,726 CANCER: CONNECTIVE AND SOFT NEOPLASMS TISSUE ****0034 M ACTIVE $79,860 $79,860 CHRONIC ISCHEMIC HEART CIRCULATORY DISEASE SYSTEM ****5065 M CANCEL $79,601 $79,601 OTHER SPONDYLOPATHIES MUSCULOSKELETAL (VERTEBRAE DISORDERS) AND CONNECTIVE TISSUE ****5139 F ACTIVE $79,556 $79,556 CROHN'S DISEASE (REGIONAL DIGESTIVE SYSTEM ENTERITIS) ****3303 F ACTIVE $79,493 $79,493 ENDOMETRIOSIS GENITOURINARY SYSTEM ****3823 M ACTIVE YES $77,226 $77,226 PAIN IN THROAT AND CHEST SYMPTOMS, SIGNS, AND ABNORMAL FINDINGS ****1381 F ACTIVE $74,711 $74,711 OSTEOARTHRITIS: HIP MUSCULOSKELETAL AND CONNECTIVE TISSUE ****7711 M ACTIVE $74,643 $74,643 ORTHOPEDIC AFTERCARE FACTORS INFLUENCING HEALTH ****5265 F ACTIVE YES $74,091 $74,091 SYNCOPE (FAINTING) AND SYMPTOMS, SIGNS, COLLAPSE AND ABNORMAL FINDINGS ****7867 F ACTIVE $73,341 $73,341 SLEEP DISORDERS NERVOUS SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 9 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****8992 M CANCEL $73,143 $73,143 THORACIC, THORACOLUMBAR AND MUSCULOSKELETAL LUMBOSACRAL INTERVERTEBRAL AND CONNECTIVE DISC DISORDERS TISSUE ****5785 F ACTIVE YES $73,104 $73,104 ENCOUNTER FOR OTHER FACTORS AFTERCARE INFLUENCING HEALTH ****8552 F ACTIVE $73,050 $73,050 HERNIA: VENTRAL DIGESTIVE SYSTEM

****6750 F ACTIVE $72,869 $72,869 MULTIPLE SCLEROSIS NERVOUS SYSTEM

****9729 F ACTIVE $72,406 $72,406 OTHER AND UNSPECIFIED NERVOUS SYSTEM POLYNEUROPATHIES (NERVE PAIN) ****4244 M ACTIVE $71,735 $71,735 CANCER: RECTUM NEOPLASMS

****2976 M ACTIVE $68,638 $68,638 MALE ERECTILE DYSFUNCTION GENITOURINARY SYSTEM ****3497 M ACTIVE $67,736 $67,736 CALCULUS (STONES) OF KIDNEY GENITOURINARY AND URETER SYSTEM ****2316 F ACTIVE YES $67,113 $67,113 OSTEOARTHRITIS: HIP MUSCULOSKELETAL AND CONNECTIVE TISSUE ****0880 M ACTIVE $66,868 $66,868 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****8352 M ACTIVE $66,805 $66,805 CHRONIC ISCHEMIC HEART CIRCULATORY DISEASE SYSTEM ****0980 M ACTIVE $66,116 $66,116 FRACTURE OF LOWER LEG INJURY, POISONING INCLUDING ANKLE AND EXTERNAL CAUSE OUTCOMES

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 10 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****8088 M ACTIVE $65,015 $65,015 OSTEOARTHRITIS: HIP MUSCULOSKELETAL AND CONNECTIVE TISSUE ****8192 M ACTIVE YES $64,771 $64,771 CANCER: LUNG AND BRONCHUS NEOPLASMS

****0474 F ACTIVE $64,662 $64,662 CEREBRAL INFARCTION (STROKE, CIRCULATORY BLOOD CLOT, BLOCKAGE, ETC.) SYSTEM ****7191 M ACTIVE YES $63,960 $63,960 BIPOLAR DISORDER MENTAL AND BEHAVIORAL DISORDERS ****3197 F ACTIVE $63,706 $63,706 OTHER DISORDERS OF THE BRAIN NERVOUS SYSTEM

****0254 M ACTIVE $62,814 $62,814 COMPLICATIONS OF INTERNAL INJURY, POISONING ORTHOPEDIC PROSTHETIC AND EXTERNAL DEVICES, IMPLANTS AND GRAFTS CAUSE OUTCOMES ****5099 F ACTIVE $62,406 $62,406 OTHER HEADACHE SYNDROMES NERVOUS SYSTEM

****2082 F ACTIVE $61,303 $61,303 CROHN'S DISEASE (REGIONAL DIGESTIVE SYSTEM ENTERITIS) ****5899 F ACTIVE $59,349 $59,349 OTHER SEPSIS (BLOOD INFECTIOUS AND INFECTIONS) PARASITIC ****7151 F ACTIVE $58,280 $58,280 EPILEPSY AND RECURRENT NERVOUS SYSTEM SEIZURES ****5845 M ACTIVE $57,593 $57,593 ESSENTIAL (PRIMARY) CIRCULATORY HYPERTENSION SYSTEM ****3017 F ACTIVE YES $57,441 $57,441 PAROXYSMAL TACHYCARDIA CIRCULATORY (RAPID HEART BEAT) SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 11 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****4478 F ACTIVE $57,397 $57,397 GASTRO-ESOPHAGEAL REFLUX DIGESTIVE SYSTEM DISEASES (GERD) ****0794 M ACTIVE $56,925 $56,925 OSTEOARTHRITIS: HIP MUSCULOSKELETAL AND CONNECTIVE TISSUE ****5599 F ACTIVE $56,803 $56,803 HERNIA: VENTRAL DIGESTIVE SYSTEM

****3523 M ACTIVE $56,021 $56,021 FRACTURE OF LOWER LEG INJURY, POISONING INCLUDING ANKLE AND EXTERNAL CAUSE OUTCOMES ****4444 F ACTIVE $55,533 $55,533 HERNIA: VENTRAL DIGESTIVE SYSTEM

****8968 F ACTIVE $55,528 $55,528 EPILEPSY AND RECURRENT NERVOUS SYSTEM SEIZURES ****7911 F ACTIVE $55,184 $55,184 BENIGN NEOPLASMS: LEIOMYOMA NEOPLASMS OF UTERUS ****6526 F ACTIVE $54,520 $54,520 FRACTURE OF LOWER LEG INJURY, POISONING INCLUDING ANKLE AND EXTERNAL CAUSE OUTCOMES ****5659 F CANCEL $53,939 $53,939 ENTHESOPATHIES (MUSCLE MUSCULOSKELETAL TENDON, LIGAMENT DISORDER), AND CONNECTIVE LOWER LIMB, EXCLUDING FOOT TISSUE ****3157 M ACTIVE $53,745 $53,745 CERVICAL DISC DISORDERS MUSCULOSKELETAL AND CONNECTIVE TISSUE ****9373 M ACTIVE $52,597 $52,597 MYOCARDIAL INFARCTION (HEART CIRCULATORY ATTACK) SYSTEM ****6610 F ACTIVE $52,259 $52,259 ENDOMETRIOSIS GENITOURINARY SYSTEM

*** PROTECTED HEALTH INFORMATION (PHI) REMOVED *** Paid : JAN 2018 through DEC 2018 Incurred : ALL CITY OF CLEVELAND > SELF FUNDED

Print Date : 1/31/2019 7:40:25PM Page 12 of 12 CLAIMANT INFORMATION PAYMENTS DISEASE/CONDITION

Referred to Highest Costing ID Number Gender Status Case Mgmt * Medical Total Medical Condition ICD 10 Chapter ****5099 M ACTIVE $52,167 $52,167 OTHER INTERSTITIAL PULMONARY RESPIRATORY DISEASES (LUNG) SYSTEM ****4618 F CANCEL YES $51,689 $51,689 DIABETES: TYPE 2 ENDOCRINE, NUTRITIONAL AND METABOLIC ****5359 M CANCEL $51,629 $51,629 PULMONARY EOSINOPHILIA RESPIRATORY (SWELLING OF THE LUNGS) SYSTEM ****1555 M ACTIVE $51,391 $51,391 OTHER AND UNSPECIFIED SPINAL NERVOUS SYSTEM CORD DISEASES ****4778 F ACTIVE $51,190 $51,190 CONGENITAL DEFORMITIES OF CONGENITAL FEET ABNORMALITIES ****9929 F ACTIVE YES $50,877 $50,877 EATING DISORDERS MENTAL AND BEHAVIORAL DISORDERS ****8108 F ACTIVE $50,870 $50,870 OTHER FUNCTIONAL INTESTINAL DIGESTIVE SYSTEM DISORDERS ****6930 F ACTIVE YES $50,490 $50,490 OPIOID RELATED DISORDERS MENTAL AND BEHAVIORAL DISORDERS ****5559 M ACTIVE $50,407 $50,407 BIRTH INJURY TO THE PERIPHERAL PERINATAL NERVOUS SYSTEM CONDITIONS ****4604 F ACTIVE $50,238 $50,238 ENCOUNTER FOR PLASTIC AND FACTORS RECONSTRUCTIVE SURGERY INFLUENCING HEALTH FOLLOWING MEDICAL PROCEDURE Grand Total : $19,021,256 $19,021,256

*A "YES" in the "Referred to Case Mgmt" column may not indicate enrollment in a Case Management program. RTOR0902 Client Reference#: 023040000008 CLAIMS SUMMARY : Payments by Line of Business - Summary All Sections