Forms.purchasing.wayne.edu

WAYNE STATE UNIVERSITY
LOSS EXPERIENCE
Claims Paid as of 12/31/2011
2008/2009 Policy Year
Ultimate with
Claims Paid
Ultimate
Loss Ratio
Domestic
International
2009/2010 Policy Year
Ultimate with
Claims Paid
Ultimate
Loss Ratio
Domestic
International
2010/2011 Policy Year
Ultimate with
Claims Paid
Ultimate
Loss Ratio
Domestic
International
WAYNE STATE UNIVERSITY
POINT IN TIME LOSS EXPERIENCE
2010/2011
2011/2012
Based on Claims Paid as of
Based on Claims Paid as of
12/31/10
12/31/11
DOMESTIC
$125,184
INTERNATIONAL
$225,939
Grand Total
$290,043
$165,093
Aetna Student Health
Wayne State University
Plan Management/Utilization Report Package Data as of Medical: December 31, 2011 Rx: November 30, 2011 *This document contains proprietary and/or confidential health information. Disclosure is strictly prohibited except as permitted or required by applicable law. Important: Aetna Student Health makes no representation or warranty of any kind, whether express or implied, with respect to the information in this report, and cannot guarantee its accuracy or completeness. Accordingly, Aetna Student Health shall not be liable for any act or omissions of third parties made in reliance on the information. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Report Package Parameters
Plan Effective Date:
August 1, 2011
Plan End Date:
July 31, 2012
Plan(s):
Policy 0474901 Plan 0000103
Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Table of Contents
Report Title
Page Number
Reconcilation of Medical Charges and Cost Sharing Analysis High Dollar Claimant(s) Detail - 2011-2012 High Dollar Claimant(s) Detail - 2010-2011 High Dollar Claimant(s) Detail - 2009-2010 Key Statistics by Generic, Brand Single-Source & Brand Multi-Source (APM) Top 25 GPI Classifications By Number of Claims (APM) - 2011-2012 Top 25 GPI Classifications By Number of Claims (APM) - 2010-2011 Top 25 GPI Classifications By Number of Claims (APM) - 2009-2010 Top 25 GPI Classifications By Paid Amount (APM) - 2011-2012 Top 25 GPI Classifications By Paid Amount (APM) - 2010-2011 Top 25 GPI Classifications By Paid Amount (APM) - 2009-2010 Top 25 Drugs Prescribed by Paid Amount (APM) - 2011-2012 Top 25 Drugs Prescribed by Paid Amount (APM) - 2010-2011 Top 25 Drugs Prescribed by Paid Amount (APM) - 2009-2010 Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Key Statistics
2009-2010
2010-2011
2011-2012
Demographics Summary for Medical*
Plan Year
Plan Year
Plan Year
Medical Paid Amount per Member
Key Statistics
Total Medical and Pharmacy Paid Amount*** Comparison of Medical Paid Amount Per Member
Total Medical Paid (Claims and Health Center) Medical Paid per Member (Claims and Health Center *Enrollment statistics reflect headcount. A member enrolled for a full or partial plan year is considered one member.
**If gender is not provided during enrollment process, gender is defaulted to female.
***Medical Paid Amounts include behavioral health.
****Aetna Pharmacy Management (APM) claims only. Pharmacy claims not run through APM are represented in Medical Paid Amount. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Demographics for Medical Membership
Member Age/Gender Comparison
Member Current Plan Year, Percent of Membership, Claimants, and Plan Paid Comparison
Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Provider Network Experience - Medical
2009-2010
2010-2011
2011-2012
Discount
In Network Experience
Plan Year
Plan Year
Plan Year Savings %
Network Discount Savings
Network Discount Savings %
% In Network Utilization Results
Note: Report does not include health center reimbursements, tax payments, access fees, or APM pharmacy claims. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Reconciliation of Medical Charges and Cost Sharing Analysis*
In-Network
Out of Network
2009-2010
2010-2011
2011-2012
2009-2010
2010-2011
2011-2012
2009-2010
2010-2011
2011-2012
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Cost Sharing % of Allowed Amount
Cost Sharing % of Allowed Amount
Cost Sharing % of Allowed Amount
2009-2010 Plan Year
2010-2011 Plan Year
2011-2012 Plan Year
*Note: Report does not include health center reimbursements, tax payments, access fees, or APM pharmacy claims Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Paid Amount by Medical Cost Category
Amount Paid
Amount Paid per Member
2009-2010
2010-2011
2011-2012
2009-2010
2010-2011
2011-2012
2009-2010
2010-2011
2011-2012
Aetna Student Health
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Inpatient:
Subtotal Inpatient:
$277,503
Outpatient:
Subtotal Outpatient:
$138,243
$158,728
Behavioral Health:
Subtotal Mental Health
Subtotal Substance Abuse
Subtotal Behavioral Health
Health Center Reimbursements:
Miscellaneous Medical:
Pharmacy:
Subtotal Pharmacy:
Total Medical and Pharmacy Paid Amount
$194,972
$452,366
*Aetna Student Health book of business (BOB) ranges represent benchmarks derived from plan utilization for the overall Aetna student health segment.
**Includes medical costs for well newborns while the mother and baby are both in the hospital. Sick babies (i.e. Preemies) are covered separately.
***Surgical Facility costs are always coded as outpatient.
****Includes Physical Therapy, Chiropractic Care, and Occupational Therapy. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Analysis by Medical Cost Category
Percentage of Total Medical Paid Amount by Medical Cost Category
Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 ICD-9 Code Range Analysis
2009-2010 Plan Year
2010-2011 Plan Year
2011-2012 Plan Year
Inpatient Paid Outpatient Paid
Inpatient Paid Outpatient Paid
Inpatient Paid Outpatient Paid
Paid Amount
Paid Amount
Paid Amount
ICD-9 Code Range
Infectious and Parasitic Diseases (001-139.9) Endocrine, Nutritional, and Metabilic Diseases, and Immunity Disorders (240-279.9) Diseases of the Blood and Blood-Forming Organs (280-289.9) Diseases of the Nervous System and Sense Organs (320-389.9) Diseases of the Circulatory System (390-459.9) Diseases of the Respiratory System (460-519.9) Diseases of the Digestive System (520-579.9) Diseases of the Genitourinary System (580-629.9) Complications of Pregnancy, Childbirth, and the Puerperium (630-677.9) Diseases of the Skin and Subcutaneous Tissue (680-709.9) Diseases of the Musculoskeletal System and Connective Tissue (710-739.9) Certain Conditions Originating in the Perinatal Period (760-779.9) Symptoms, Signs, and Ill-defined Conditions (780-799.9) $186,221
$141,632
$444,506
$281,003
$163,503
Note: Report does not include Health Center Reimbursements, Tax Payments, Access Fees, or APM Pharmacy Claims. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top Provider Report* - 2011-2012
Inpatient as
Outpatient as
City State
Total Medical
Inpatient
% of Total
Outpatient
% of Total
Provider Name***
In Network
Zip Code****
of Claimants
Paid Amount
Paid Amount
Paid Amount
Paid Amount
Paid Amount
*Includes top 25 providers year to date by total medical paid amount.
**Multiple providers with the same Tax ID are considered the same provider for purposes of this report. Provider Name represents the name with the largest dollar amount under a Tax ID.
***In and Out of Network providers with the same Tax ID will appear as separate providers on this report.
****City, State and Zip Code may reflect the billing address of the provider and not geographic location. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top Provider Report* - 2010-2011
Inpatient as
Outpatient as
City State
Total Medical
Inpatient
% of Total
Outpatient
% of Total
Provider Name***
In Network
Zip Code****
of Claimants
Paid Amount
Paid Amount
Paid Amount
Paid Amount
Paid Amount
DR. L. REYNOLDS & AS SOCIATES, P.C.
$410,150
$271,267
$138,883
*Includes top 25 providers year to date by total medical paid amount.
**Multiple providers with the same Tax ID are considered the same provider for purposes of this report. Provider Name represents the name with the largest dollar amount under a Tax ID.
***In and Out of Network providers with the same Tax ID will appear as separate providers on this report.
****City, State and Zip Code may reflect the billing address of the provider and not geographic location. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top Provider Report* - 2009-2010
Inpatient as
Outpatient as
City State
Total Medical
Inpatient
% of Total
Outpatient
% of Total
Provider Name***
In Network
Zip Code****
of Claimants
Paid Amount
Paid Amount
Paid Amount
Paid Amount
Paid Amount
DR. L. REYNOLDS & AS SOCIATES, P.C.
$166,228
$122,182
*Includes top 25 providers year to date by total medical paid amount.
**Multiple providers with the same Tax ID are considered the same provider for purposes of this report. Provider Name represents the name with the largest dollar amount under a Tax ID.
***In and Out of Network providers with the same Tax ID will appear as separate providers on this report.
****City, State and Zip Code may reflect the billing address of the provider and not geographic location. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Impact of High Dollar Claimant(s)
High Dollar Claimant Threshold: $25,000
All Claimants
Claimants Above Threshold*
2009-2010
2010-2011
2011-2012
2009-2010
2010-2011
2011-2012
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Plan Year
Net of High Dollar Claimants
Paid Amount per Member
With & Without High Dollar Claimants
Note: Report does not include Health Center Reimbursements, Tax Payments, Access Fees, or APM Pharmacy Claims.
*See Medical High Dollar Claimant Detail Reports for detail on claimants above the threshold for current and prior periods. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 High Dollar Claimant(s) Detail - 2011-2012
Claimants Exceeding $25,000
Relationship
Total Medical
Inpatient
Outpatient
Claimant
Paid Amount
Paid Amount
Paid Amount
ICD-9 Description
Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 High Dollar Claimant(s) Detail - 2010-2011
Claimants Exceeding $25,000
Relationship
Total Medical
Inpatient
Outpatient
Claimant
Paid Amount
Paid Amount
Paid Amount
ICD-9 Description
$251,394
$179,789
1707 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 High Dollar Claimant(s) Detail - 2009-2010
Claimants Exceeding $25,000
Relationship
Total Medical
Inpatient
Outpatient
Claimant
Paid Amount
Paid Amount
Paid Amount
ICD-9 Description
1707 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB 5409 ACUTE APPENDICITIS W\O MENTION OF PERITONITIS Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Claimant Distribution - by Paid Amount - 2011-2012
Medical Claimant Distribution
Dependent
Claimant Distribution
*Eligible members who have submitted a claim with no benefit payment (i.e. copays, deductibles). Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Claimant Distribution - by Paid Amount - 2010-2011
Medical Claimant Distribution
Dependent
Claimant Distribution
*Eligible members who have submitted a claim with no benefit payment (i.e. copays, deductibles). Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Claimant Distribution - by Paid Amount - 2009-2010
Medical Claimant Distribution
Dependent
Claimant Distribution
*Eligible members who have submitted a claim with no benefit payment (i.e. copays, deductibles). Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Key Statistics - Pharmacy (APM)
2009-2010
2010-2011
2011-2012
Demographics Summary*
Plan Year
Plan Year
Plan Year
Pharmacy Paid Amount per Eligible Member
Number of Pharmacy Claims Per Eligible
Key Statistics
Pharmacy Paid Amount per Utilizing Member Number of Pharmacy Claims per Eligible Member Number of Pharmacy Claims per Utilizing Member Average Out of Pocket and Average Paid
Amount Per Claim
*Enrollment statistics reflect headcount on plans with APM coverage. A member enrolled for a full or partial plan year is considered one member.
**Includes all Rx expenses paid by the member including copays, deductibles, co-insurance, and any submitted amounts over the plan maximums. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Key Statistics By Generic, Brand Single-Source, & Brand Multi-Source (APM)
2009-2010
2010-2011
2011-2012
Average Amount Paid Per Claim
Plan Year
Plan Year
Plan Year
Generic Pharmacy Paid Amount per Eligible Member Generic Pharmacy Paid Amount per Utilizing Member Number of Generic Pharmacy Claims per Eligible Member Brand Single-Source
Brand Single-Source Pharmacy Paid Amount per Eligible Member Brand Single-Source Pharmacy Paid Amount per Utilizing Member Utilization by Generic, Brand Single-Source, and Brand Multi-
Number of Brand Single-Source Pharmacy Claims per Eligible Member Brand Multi-Source
Brand Multi-Source Pharmacy Paid Amount per Eligible Member Brand Multi-Source Pharmacy Paid Amount per Utilizing Member Number of Brand Multi-Source Pharmacy Claims per Eligible Member Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 GPI Classifications By Number of Claims (APM) - 2011-2012
Number of
Calculated
Average Paid
Paid Amount
Utilizing
Percent of
Ingredient
Per Utilizing
GPI Classification
of Claims
Utilization
Utilization
All Claims
Per Claim
Nonsteroidal Anti-inflammatory Agents (NSAIDs) Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 GPI Classifications By Number of Claims (APM) - 2010-2011
Number of
Calculated
Average Paid
Paid Amount
Utilizing
Percent of
Ingredient
Per Utilizing
GPI Classification
of Claims
Utilization
Utilization
All Claims
Per Claim
Nonsteroidal Anti-inflammatory Agents (NSAIDs) Selective Serotonin Reuptake Inhibitors (SSRIs) Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 GPI Classifications By Number of Claims (APM) - 2009-2010
Number of
Calculated
Average Paid
Paid Amount
Utilizing
Percent of
Ingredient
Per Utilizing
GPI Classification
of Claims
Utilization
Utilization
All Claims
Per Claim
Nonsteroidal Anti-inflammatory Agents (NSAIDs) Selective Serotonin Reuptake Inhibitors (SSRIs) Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 GPI Classifications By Paid Amount (APM) - 2011-2012
Number of
Calculated
Percent of
Average Paid
Paid Amount
Utilizing
Percent of
Ingredient
Per Utilizing
GPI Classification
of Claims
All Claims
Paid Amount
Per Claim
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Angiotensin II Receptor Antag & Ca Channel Blocker C Non-Benzodiazepine - GABA-Receptor Modulators Selective Serotonin Reuptake Inhibitors (SSRIs) Nonsteroidal Anti-inflammatory Agents (NSAIDs) Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 GPI Classifications By Paid Amount (APM) - 2010-2011
Number of
Calculated
Percent of
Average Paid
Paid Amount
Utilizing
Percent of
Ingredient
Per Utilizing
GPI Classification
of Claims
All Claims
Paid Amount
Per Claim
Inosine Monophosphate Dehydrogenase Inhibitors Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Non-Benzodiazepine - GABA-Receptor Modulators Selective Serotonin Reuptake Inhibitors (SSRIs) Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 GPI Classifications By Paid Amount (APM) - 2009-2010
Number of
Calculated
Percent of
Average Paid
Paid Amount
Utilizing
Percent of
Ingredient
Per Utilizing
GPI Classification
of Claims
All Claims
Paid Amount
Per Claim
Antiretrovirals - RTI-Nucleotide Analogues Selective Serotonin Reuptake Inhibitors (SSRIs) Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 Drugs Prescribed by Paid Amount (APM) - 2011-2012
Number of
Number of
Drug Name
GPI Classification
Claimants
Amount Paid
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Angiotensin II Receptor Antag & Ca Channel Blocker Comb Non-Benzodiazepine - GABA-Receptor Modulators Selective Serotonin Reuptake Inhibitors (SSRIs) Nonsteroidal Anti-inflammatory Agents (NSAIDs) Note: Multiple dosages of the same drug are listed as one line for the purposes of this report. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 Drugs Prescribed by Paid Amount (APM) - 2010-2011
Number of
Number of
Drug Name
GPI Classification
Claimants
Amount Paid
Inosine Monophosphate Dehydrogenase Inhibitors Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Non-Benzodiazepine - GABA-Receptor Modulators Selective Serotonin Reuptake Inhibitors (SSRIs) Note: Multiple dosages of the same drug are listed as one line for the purposes of this report. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Top 25 Drugs Prescribed by Paid Amount (APM) - 2009-2010
Number of
Number of
Drug Name
GPI Classification
Claimants
Amount Paid
Antiretrovirals - RTI-Nucleotide Analogues Selective Serotonin Reuptake Inhibitors (SSRIs) Note: Multiple dosages of the same drug are listed as one line for the purposes of this report. Aetna Student Health
Wayne State University
Data as of Medical: December 31, 2011 Rx: November 30, 2011 Financial Overview
Total Health Center
Pharmacy
Number of Students
Premium *
Reimbursement
Paid Amount
Paid Amount
2009-2010 Plan Year:
$194,972
2010-2011 Plan Year:
$452,366
2011-2012 Plan Year:
*Paid premium includes payments received and processed (YTD) from the Client School, as well as any Voluntary or Dependent premium received from individual students/dependents attending that Client School. These payments may be net of estimated administrative fees and/or Broker Fees, and would/can include premiums related to other products (I.e. Worldwide Assist (AD&D), Student Assistance Program (SAP), Vital Savings, etc.), which are included in the student and dependent's rate, but excluded from overall loss ratio calculations. **Refers to claims processed under programs beginning prior to the main program effective date. Glossary - Medical
Admission
Confinement as inpatient in a hospital. (Includes partial hospitalizations as multiple admissions) Admissions/1,000 Members
Total admissions divided by members per 1,000. Allowed Amount
Total amount allowed under the medical plan including the enrollee's paid portion of deductibles, copays, coinsurance, the planpaid portion (paid amount) and COB. Allowed amount does not include plan and administrative exclusions such as duplicateclaims, ineligible claims, network discount savings and R&C savings.
Ambulatory / Outpatient Care
Health services provided without the patient being admitted.
APM Pharmacy Claims
The total RX amount paid by the insurance plan for claims under the Aetna Pharmacy Management plan.
Average Age of Students
The sum of ages of all students divided by the number of students.
Average Discount Savings
In-network financial savings expressed on a per admission basis.
per Admission
Average Length of Stay
Total inpatient days of care divided by total admissions.
Average Paid Amount per Claimant
The total paid amount divided by the total number of claimants.
Behavioral Health
An umbrella term that includes mental health, psychiatric, marriage and family counseling, and addictions treatment. Many stateshave "parity" laws that attempt to require that behavioral health insurance coverage be provided "on par" to physical healthcoverages.
Behavioral Health Paid Amount Per Member
The total paid amount for behavioral health divided by the total numbers of members.
Billed Network Charges (before discount)
The actual charge for a covered service by the provider that furnishes it.
Aetna Student Health BOB
Benchmark ranges derived from Aetna Student Health Book-of-Business average experience.
Claimant / Utilizing Member
A member who has submitted a claim under the medical or RX portion of the program.
Coinsurance
The total amount of covered expenses payable by the member under the insurance plan.
The amount that must be paid by the covered person at the time services are rendered by a preferred provider. Copay amountsare the responsibility of the covered person.
Deductible
A specific amount of covered expenses that must be incurred and paid for by the member before benefits are payable under theplan. Deductible amounts are the responsibility of the covered person.
Dependent
Spouses or domestic partners and/or child or children covered under the medical plan.
Disallowed
Amounts above reasonable charge and denied claims.
Supplemental classification of external causes of injury and poisoning.
Eligible Charges
Generic Product Identifier. A general classification of drugs used to identify a group of drugs into like-therapeutic classes.
Health Center Capitation per Member
The total amount of capitation payments expressed on a per member basis (applies to capitated medical arrangements only).
Health Center Charges per Member
Charges for services rendered at the Student Health Center based on a fee schedule agreement divided by the number of members.
Health Center Reimbursements
Health Center Capitation plus Health Center Charges IDC-9 Code
Codes used to classify diseases, symptoms, and abnormal findings based on Incremental Classification of Diseases, 9th Revision.
In-Network / Preferred Care
An affiliation of providers through formal and informal contracts and agreements.
Inpatient Ancillary
Includes items such as laboratory, radiology, and physical therapy.
Inpatient Facility
Facilities that provide care in an inpatient setting versus ambulatory (outpatient).
Glossary - Medical
Insurance Plan Percent Share Medical
The Insurance Plan paid portion divided by the Allowed Amount.
Insurance Plan Paid Portion
The total medical paid amount by the insurance plan.
Medical Paid Amount - Dependents
The amount paid by the insurance plan on dependent (spouse/domestic partner and child) claims.
Medical Paid Amount - Students
The amount paid by the insurance plan on student claims.
A covered student or dependent who is enrolled under the insurance program.
Member Percent Share Medical
Total member cost sharing divided by the Allowed Amount Member Paid Portion per Member
The total of deductibles, copays and coinsurance paid by members expressed on a per member basis.
Miscellaneous Medical
Includes items such as ambulance, dental injury, durable medical equipment, wisdom teeth removal, and home health care.
Network Discount Savings
The total savings to the plan due to the application of negotiated discount arrangements with contracted providers.
Number of Claimants
The total number of unique utilizing members.
Number of Dependents
The number of dependents (spouses or domestic partners and/or child or children) covered under the medical plan.
Number of Members
The number of students and dependents covered under the medical plan.
Other Pharmacy Claims
The total amount paid by the insurance plan for pharmacy claims under the medical plan (not covered under Aetna PharmacyManagement).
Out of Network / Non-Preferred Care
A health care service or supply furnished by a health care provider that is not In-Network.
Paid premium includes payments received and processed (YTD) from the Client School, as well as any Voluntary or Dependentpremium received from individual students/dependents attending that Client School. These payments may be net of estimatedadministrative fees and/or Broker Fees, and would/can include premiums related to other products (I.e. Worldwide Assist (AD&D),Student Assistance Program (SAP), Vital Savings, etc.), which are included in the student and dependent's rate, but excluded fromoverall loss ratio calculations. Submitted Charges
Billed charges, excluding duplicates but including denied claims.
Total Member Cost Sharing
Copay, deductible and coinsurance amounts paid by the member.
Total Pharmacy Paid Amount
Calculated as Ingredient Cost + Dispensing Fee + Sales Tax - Copay Amount.
A Diagnosis which is not a sickness or injury, such as preventative care, immunizations, and maternity deliveries.
Glossary- Pharmacy
Average Age of Students
The sum of ages of all students divided by the number of students.
Average Brand Multi-Source
The total brand multi-source pharmacy paid amount divided by the number of brand multi-source pharmacy claims.
Paid Amount per Claim
Average Brand Single-Source
The total brand single-source pharmacy paid amount divided by the number of brand single-source pharmacy claims.
Paid Amount per Claim
Average Generic Paid
The total generic pharmacy paid amount divided by the number of generic pharmacy claims.
Amount per Claim
Average Paid Amount per Claim
The total pharmacy paid amount divided by the total number of pharmacy claims.
Brand Multi-Source Prescription Drug
Brand name drugs manufactured by multiple pharmaceutical companies. Brand multi-source prescription drugs also have a generic equivalent.
Brand Multi-Source Utilization
The percent of total claims that were brand multi-source drugs.
Brand Name Prescription Drug
A prescription drug which is protected by trademark registration.
Brand Single-Source Prescription Drug
Brand name drugs manufactured by a single pharmaceutical company. Brand single-source prescription drugs do not have a generic equivalent.
Brand Single-Source Utilization
The percent of total claims that were brand single-source drugs.
Brand Utilization
The percentage of total prescriptions that were dispensed as brand drugs.
Calculated Ingredient Cost
The Calculated Ingredient Cost is the lesser of: a) The Average Wholesale Price (AWP) - Percentage Discount; (b) Maximum Allowable Cost (MAC); or (c) The Reasonable and Customary Cost. The Calculated Ingredient Cost does not include the dispensing fee or the copay.
Claimant / Utilizing Member
A member who has submitted a claim under the medical or RX portion of the program.
Dependent
Spouses or domestic partners and/or child or children covered under the medical plan.
Formulary Prescription Drug
An approved list of prescription drugs as determined by APM. This list is subject to change every calendar year.
Formulary Utilization
The percentage of total prescriptions that were dispensed on the Formulary list.
Generic Prescription Drug
A prescription drug which is not protected by trademark registration, but is produced and sold under the chemical formulation name.
Generic Substitution
The process of substituting a lower cost generic version of a brand-name drug, when available. Generic Utilization
The percentage of total prescriptions dispensed as generic drugs. The generic utilization rate is highly dependent on benefit plan design (i.e., the presence or absence of a differential copay between brand and generic drugs).
Mail-Order Prescription Drug
An establishment where prescription drugs are legally dispensed by mail.
Mail-Order Utilization
Percent of mail order drugs divided by the prescription drug total.
A covered student or dependent who is enrolled under the insurance program.
Number of Dependents
The number of dependents (spouses or domestic partners and/or child or children) covered under the medical plan.
Number of Members
The number of students and dependents covered under the medical plan.
Total Member Out of Pocket Amount (Rx)
Copay, deductible and coinsurance amounts paid by the member.

Source: http://forms.purchasing.wayne.edu/Adv_bid/RFP_International_Student_Insurance_2012_Utilization_Overview_Rates.pdf