franklin county, virginia medical/rx rfp exhibits
TRANSCRIPT
Franklin County, VirginiaMedical/Rx RFP ExhibitsTo be completed and returned as part of the proposal
Please complete these exhibits.
Provider Checklist - Indicate if the listed providers are in your HMO/POS network and your PPO network.
Rx Checklist - Indicate under which tier each prescription drug falls.
The following exhibits should be completed for both the current plan design and the alternative plan design.E1 - Underwriting Analysis E2 - FeesE3 - Rate QuotationE4 - Underwriting Assumptions and Deviations
USI Insurance Services
Franklin County, VirginiaTop Provider Report
Please indicate if these providers participate in your network by placing an "X" in the appropriate box.
PRV_ID PROVIDER_TIN Provider Name Provider Address Provider Add 2Provider State
Provider Zip Code Provider Type Provider Specialty HMO/POS PPO
200002178282 222405059 Bio Reference Laboratories Inc 481 Edward H Ross Dr NJ 074073118 Laboratory200002214869 113454103 Carecentrix Inc 7725 Woodland Center Blvd Ste 100 FL 336142426 Other Hospital200002301712 061755234 Lewis Gale Physicians Llc 1802 Braeburn Dr Ste 1310 VA 241537357 Medical Group Surgery - Orthopedic200002306753 383721709 John Randolph Ob Gyn Llc PO Box 403744 GA 303843744 Medical Group Obstetrics and Gynecology200002312322 540506332 Carilion Roanoke Memorial Hospital 1906 Belleview Ave VA 240141838 General Hospital200002339811 020691413 Southside Regional Medical Center 200 Medical Park Blvd VA 238059274 General Hospital200002340543 541686589 Rmh Emergency Services Llc PO Box 75123 MD 212755123 Medical Group Emergency Medicine200002342492 540519577 Mary Washington Hospital 1001 Sam Perry Blvd VA 224014453 General Hospital200002374861 540553805 Carilion New River Valley Medical CentePO Box 75099 MD 212755099 General Hospital200002378050 540851534 Radiology Associates Of Roanoke Pc 1900 Electric Rd VA 241537474 Medical Group Radiology200002380601 520962668 Emergency Medicine Assoc 20010 Century Blvd Ste 200 MD 208741118 Medical Group Emergency Medicine200002400680 202028539 Sovah Health 142 S Main St VA 245412922 General Hospital200002405264 541910038 Commonwealth Lab Consultants Pc 7101 Jahnke Rd VA 232254017 Medical Group Pathology, Clinical200002457665 840611484 Laboratory Corporation Of America PO Box 2270 NC 272162270 Laboratory200002473542 621636465 Bristol Regional Medical Center 1 Medical Park Blvd Ste 5 TN 376207430 General Hospital200002515807 621695507 Apllc PO Box 639195 OH 452639195 Laboratory200002562510 311799466 Briggs, Addie J. 4744 Finlay St VA 232312754 PCP Type Pediatrics200002612615 542004894 Martin IV, William D. 6500 Harbour View Ct Ste 102 VA 231122157 PCP Type Family Practice200002630613 541931095 Mc Gillivray Smith, Bren A. 250 Old Mill Ln VA 228152754 Counselor Counseling200002650507 061755240 Blue Ridge Surgery Center 1802 Braeburn Dr VA 241537357 Ambulatory Surgery Center200002748337 541628472 Melchert, Andrew J. 6010 W Broad St VA 232302215 Chiropractor Chiropractic Medicine200002848491 620476282 Johnson City Medical Center 400 N State Of Franklin Rd TN 37604 General Hospital200002853630 541820093 Depaul Medical Center 150 Kingsley Ln VA 235054602 General Hospital200002858249 382084239 Quest Diagnostics Clinical Laboratories PO Box 827641 PA 191827641 Laboratory200002860639 621771540 Poplar Healthcare Pllc 3495 Hacks Cross Rd TN 38125 Laboratory200002860652 540551711 Community Memorial Healthcenter 1755 N Mecklenburg Ave VA 239704080 General Hospital200002878801 540793767 St Marys Hospital 5801 Bremo Rd VA 232261907 General Hospital200002882144 541779911 Chippenham Jw Hospital 1401 Johnston Willis Dr VA 232354730 General Hospital200002891074 541741450 Miller, Carlton E. 430 Claremont Ct Ste 122A VA 238341770 Medical Doctor Rheumatology200002904439 541915570 Endocrinology Association Inc 8650 Sudley Rd Ste 412 VA 201104419 Medical Clinic Endo, Diabetes & Metabolism200002908912 520890739 Quest Diagnostics Incorporated Md 1145 19th St NW Ste 308 DC 200363740 Laboratory200003105625 540888075 Fidler JR, Robert Y. 2602 Buford Rd VA 232353422 Radiologist Radiology200003266381 541470544 Moore II, Gregory P. 7101 Jahnke Rd Ste 280 VA 232254017 PCP Type Obstetrics and Gynecology200003316645 421613859 Tolliver, David L. 110 Huffard Dr VA 246059209 Medical Doctor Dermatology200003356271 621388079 Samuel Jr, Dennis C. 2204 Pavilion Dr Ste 200 TN 376604652 PCP Type Obstetrics and Gynecology200003524713 541848065 Vcu Health System Dba Medical College 1250 E Marshall St VA 232985051 General Hospital200003531323 541671658 Killeen, Karen L. 1508 Willow Lawn Dr Ste 117 VA 232303421 Hospitalist Radiology, Diagnostic200003575972 541177354 Rife, Charles A. 5401 Fallowater Ln Ste C VA 240180949 Counselor Social Work200003589290 585515533 Park, Chan M. 6460 Greensboro Rd VA 241483478 PCP Type Family Practice200003670200 541031488 Stickle, Robert A. 20370 Timberlake Rd VA 245027213 Chiropractor Chiropractic Medicine200003670200 541031488 Stickle, Robert A. 20370 Timberlake Rd VA 245027213 Chiropractor Chiropractic Medicine200003688353 540910545 Mutch, Justin A. 1212 McConville Rd VA 245024536 PCP Type Pediatrics200003735964 020750477 Divers, Allison K. PO Box 18237 VA 240140824 Medical Doctor Dermatology200003883388 542033006 Szilagyi, Michael S. 1906 Belleview Ave SE VA 240141838 Hospitalist Emergency Medicine200004089572 541580549 Hamman, Chelsea C. 1048 Terrace Dr VA 243544138 PCP Type Family Practice200004134215 223726811 Djebiyan, Eli S. 140 Grand Ave Ste 3 NJ 076316582 PCP Type Internal Medicine200004135327 541027713 Shaia, Wayne T. 10200 Three Chopt Rd Ste A VA 232332083 Medical Doctor Otolaryngology200004135597 541418040 Floyd, Julie M. 120 Executive Center Pkwy VA 224013100 PCP Type Family Practice200004142418 430654872 Cornelius, Victoria E. 1465 S Grand Blvd MO 631041003 PCP Type Internal Medicine200004175027 540647482 Richmond Community Hospital 1500 N 28th St VA 232235332 General Hospital200004211761 061755234 Keilman, David A. 4910 Valley View Blvd NW VA 240122040 PCP Type Family Practice200004224218 540883363 Brown, Jennifer B. 3000 Watercove Rd VA 231123982 PCP Type Family Practice200004259150 540853078 Scothorn, Donald M. 70 Summerfield Ct VA 240194579 Optometrist Optometry200004282905 061755234 Delaney, Russell E. 1802 Braeburn Dr VA 241537357 PCP Type Pediatrics200004288207 540892414 Zachmann, Gregory C. 1234 Franklin Rd SW VA 240164606 Medical Doctor Otolaryngology
Place an "X" in this column if provider is in
your HMO/POS network
Place an "X" in this column if provider is in
your PPO network
Franklin County, VirginiaTop Provider Report
Please indicate if these providers participate in your network by placing an "X" in the appropriate box.
PRV_ID PROVIDER_TIN Provider Name Provider Address Provider Add 2Provider State
Provider Zip Code Provider Type Provider Specialty HMO/POS PPO
Place an "X" in this column if provider is in
your HMO/POS network
Place an "X" in this column if provider is in
your PPO network
200004304233 541210285 Cronk, Paul H. 217 Albemarle Ave SW VA 240164716 Chiropractor Chiropractic Medicine200004336217 542025695 Lee, John C. 2342 Colony Crossing Pl VA 231124280 Medical Doctor Psychiatry200004349870 541392125 Starkey, Gary L. 3300 Academy Ave VA 237033205 Medical Doctor Psychiatry200004354376 540942125 Seward, Robert L. 7149 Jahnke Rd VA 232254017 Medical Doctor Psychiatry200004354680 542061304 Chiglinsky, Joanne L. 3247 Electric Rd Ste 1A VA 240186448 Social Worker Social Work200004411553 208672011 Minuteclinic Diagnostic Of Virginia Llc PO Box 8444 ME 049158444 PCP Type Family Practice200004478391 540896390 Pratt Medical Center 2300 Fall Hill Ave Ste 207 VA 224013342 Medical Group Family Practice200004641774 133757370 Labcorp Holdings PO Box 2270 NC 272162270 Laboratory200004651036 540888075 Radiology Associates Of Richmond Inc 8580 Magellan Pkwy VA 232271149 Medical Group Radiology200004651196 541119248 Slott, Jeffrey H. 7575 Cold Harbor Rd Ste 1A VA 231111600 Other/Professional Ophthalmology200004662031 540544705 Johnston Memorial Hospital 351 Court St VA 24210 General Hospital200004673593 540883363 Little, Margaret A. 5875 Bremo Rd Ste 304 VA 232261934 PCP Type Family Practice200004781221 361924025 Walgreen Co PO Box 90480 IL 606960480 PCP Type Family Practice200004801903 546001796 Uva Health Sciences Ctr 1215 Lee St Ste PFS VA 229080816 General Hospital200004889986 200999466 Cmh Physicians Services Llc 420 Bracey Ln VA 239701631 Medical Group Pediatrics200004890021 311716973 St Francis Medical Center 13710 St Francis Blvd VA 231143267 General Hospital200004911699 541586601 Zimmer, William J. 315 Hospital Dr Ste 101 VA 241121927 PCP Type Internal Medicine200004919899 541586601 Whitney Iii, William P. 3369 Colonial Ave SW VA 240183739 PCP Type Family Practice200004920622 541586601 Brady, Don I. 3390 Colonial Ave VA 240183740 PCP Type Family Practice200004928826 342029779 Chesterfield Imaging Center Llc 13636 Hull Street Rd VA 231122108 Radiology/Xray Facility200004934600 541768662 Alexander III, Burton F. 500 Sentara Cir Ste 203 VA 231885727 Medical Doctor Hematology200004935841 541820401 Jafri, Naved A. 716 Denbigh Blvd Ste B3 VA 236084414 PCP Type Obstetrics and Gynecology200004945353 541432505 Ball, William F. PO Box 4127 VA 240150127 PCP Type Family Practice200004945723 541878891 Weston, James S. 606 Randolph St VA 241412448 PCP Type Obstetrics and Gynecology200004945757 621760148 Lewis Gale Medical Center Llc 1900 Electric Rd VA 241537474 General Hospital200004946474 541908029 Shah, Hemang H. 4480 Holland Rd Ste Park STE PARK VA 23452 Medical Doctor Neurology200004946597 541671658 Worthington, Janette L. 1508 Willow Lawn Dr Ste 117 VA 232303421 Radiologist Radiology200004947670 541064694 Port, Carolyn C. 4786 Finlay St VA 232312754 PCP Type Pediatrics200004980950 262188459 Kidmed Inc 4687 Pouncey Tract Rd VA 230595802 Urgent Care Services200005062110 540506332 Whitmer, Kelley K. 180 Floyd Ave VA 241511318 Hospitalist Radiology, Diagnostic200005062115 540506332 Johnson, Isaiah M. 902 S Jefferson St VA 240164404 PCP Type Obstetrics and Gynecology200005069446 540506332 Dziadzio, Laura L. 102 Highland Ave SE Ste 203 VA 240132254 Medical Doctor Allergy200005117779 561029437 Wiener, John S. 3480 Wake Forest Rd Ste 310 NC 276097376 Medical Doctor Urology200005132012 432100402 Lewis Gale Imaging At Brambleton PO Box 405702 GA 303845702 Radiology/Xray Facility200005146977 541621891 Joiner JR, Murray E. 1945 Thomson Dr VA 245011025 Hospitalist Physical Medicine200005176266 562017400 Solstas Lab Partners Group Llc 4380 Federal Dr Ste 100 NC 27410 Laboratory200005179391 841699629 Rpn Of Va Inc PO Box 633491 OH 452633491 Rehab/Phys/Occup/Spch Therapy200005242652 271117058 Cleveland Heartlab Inc 6701 Carnegie Ave Ste 500 OH 441034623 Laboratory200005285852 450541861 Heid, Ryan M. 6003 Harbour Park Dr VA 231122160 Chiropractor Chiropractic Medicine200005324582 261747446 Smith, Nina K. 1956 Evelyn Byrd Ave Ste B VA 228013423 PCP Type Obstetrics and Gynecology200005356597 540921950 Judy, Charles R. 600 Randolph St VA 241412428 PCP Type Family Practice200005385334 541586601 Watts, Earl M. 37 Laymantown Rd VA 241756635 PCP Type Family Practice200005385490 541586601 Polk, Elizabeth L. 46 Wesley Rd VA 240833082 PCP Type Family Practice200005385517 540881356 Musgrave, Donna L. 21 Highland Ave SE Ste 200 VA 240132218 PCP Type Obstetrics and Gynecology200005385587 540881356 Arliss, Jill M. 21 Highland Ave SE Ste 200 VA 240132218 PCP Type Obstetrics and Gynecology200005385609 541586601 Ernst, Benjamin D. 415 S Pollard St VA 241792502 PCP Type Family Practice200005385766 540885056 Mc Bride, Mark A. 21 Highland Ave SE Ste 100 VA 240132218 PCP Type Pediatrics200005385969 540885056 Burton, Floyd R. 21 Highland Ave SW Ste 100 VA 240164411 PCP Type Pediatrics200005386176 562292531 Burgoon, Michael S. 2302 Colonial Ave SW Ste A VA 240153100 Chiropractor Chiropractic Medicine200005386189 541586601 Young, Deana A. 213 S Jefferson St Ste 625 VA 240111712 PCP Type Family Practice200005386260 541567372 Mcelroy, Paul G. 805 Davis St VA 240607013 PCP Type Pediatrics200005386379 541586601 Pierce, Christopher A. 89 Summers Way Ste 201 VA 240198291 PCP Type Pediatrics200005386520 541586601 Patterson, Mark A. 89 Summers Way Ste 201 VA 240198291 PCP Type Pediatrics200005386521 540881356 Gaines, Jill A. 21 Highland Ave SE Ste 200 VA 240132218 PCP Type Obstetrics and Gynecology200005386594 540885056 Johnson Privitera, Camron L. 21 Highland Ave SE Ste 100 VA 240132218 PCP Type Pediatrics
Franklin County, VirginiaTop Provider Report
Please indicate if these providers participate in your network by placing an "X" in the appropriate box.
PRV_ID PROVIDER_TIN Provider Name Provider Address Provider Add 2Provider State
Provider Zip Code Provider Type Provider Specialty HMO/POS PPO
Place an "X" in this column if provider is in
your HMO/POS network
Place an "X" in this column if provider is in
your PPO network
200005386729 541586601 Kellam, Stephen J. 3369 Colonial Ave SW VA 240183739 PCP Type Family Practice200005386737 540885056 Nelson, Kelly K. 21 Highland Ave SE Ste 100 VA 240132218 PCP Type Pediatrics200005386808 541586601 Arthur, Christy L. 1314 Peters Creek Rd NW VA 240172500 PCP Type Family Practice200005386899 541203530 Bassignani, Matthew J. 500 Ray C Hunt Dr Ste Rudge STE RUDGE VA 229032981 Hospitalist Radiology, Diagnostic200005386906 541086974 Seamon, David W. 15 Cleveland Ave Ste 14 VA 241122937 PCP Type Pediatrics200005387021 541902938 Cummings, David A. 4079 Electric Rd VA 240188442 PCP Type Family Practice200005387065 541586601 Palmerton, Todd S. 6415 Peters Creek Rd VA 240194021 PCP Type Family Practice200005414056 311569568 Kroger Limited Partnership I PO Box 842772 MA 022842772 PCP Type Family Practice200005416763 050340626 Cvs Pharmacy Inc 1 Cvs Dr RI 028956146 PCP Type Family Practice200005431499 262616622 Kennedy Chiropractic Inc 1461 W Main St VA 241533120 Medical Group Chiropractic Medicine200005431574 541856112 Eapen, Saju S. PO Box 8480 VA 240140480 Medical Doctor Allergy/Immunology200005478862 540973055 Smith, David M. PO Box 5468 VA 241155468 Hospitalist Pathology200005499649 273069705 Demay, Jessica M. 7611 Forest Ave Ste 200 VA 232294946 PCP Type Obstetrics and Gynecology200005501504 061755234 Bouldin, John W. 1802 Braeburn Dr VA 241537357 PCP Type Pediatrics200005517633 273131290 Kidmed Southside Plc 5021 Craig Rath Blvd Bldg IV VA 231126243 Urgent Care Services200005540229 540881356 Chewning, Mark W. 21 Highland Ave SE Ste 200 VA 240132218 PCP Type Obstetrics and Gynecology200005544488 542029108 Algino, Kenneth M. 101 Elm Ave SE VA 240132222 Hospitalist Pathology200005544786 061755234 Cummings, Joyce A. 1802 Braeburn Dr VA 241537357 PCP Type Pediatrics200005544866 541820401 Leao, Zenette M. 516 Innovation Dr Ste 305 VA 233203866 PCP Type Obstetrics and Gynecology200005545018 542029108 Sheth, Pragna D. Belleview Ave & Jefferson St VA 24014 Hospitalist Pathology200005546003 541820401 Harris Proctor, Denise L. 880 Kempsville Rd Ste 2200 VA 235023990 PCP Type Obstetrics and Gynecology200005546115 541586601 Llavore, Jo Anne A. 3369 Colonial Ave SW VA 240183739 PCP Type Family Practice200005546237 521576648 Bocca, Silvina M. 601 Colley Ave Ste 229 VA 235071627 PCP Type Obstetrics and Gynecology200005546341 541595397 Amabile, Anthony T. 816 Independence Blvd Ste 18-H VA 234556010 PCP Type Internal Medicine200005546366 542029108 Budin, Robert E. 1906 Belleview Ave SE Fl 3 VA 240141838 Hospitalist Pathology200005546879 541794094 Jones Ii, Ezekiel N. 431 Apperson Dr VA 241537026 PCP Type Family Practice200005551776 541586601 Harris, William K. 6415 Peters Creek Rd VA 240194021 PCP Type Family Practice200005551789 540506463 Skinner, Alison C. 3253 Taylor Rd Ste 107 VA 233212452 PCP Type Family Practice200005554290 541114277 Veg Office Richmond Gastro 215 Wadsworth Dr VA 232364510 Ambulatory Surgery Center200005554985 541547408 Sentara Norfolk General Hospital 600 Gresham Dr VA 235071904 General Hospital200005555161 541744931 Memorial Regional Medical Center 8260 Atlee Rd VA 231161844 General Hospital200005555976 273069705 Tate, Alexandra J. 5801 Bremo Rd VA 232261907 PCP Type Obstetrics and Gynecology200005566995 542052809 Powers, Kevin L. 4000 Glenside Dr Ste A VA 232284102 PCP Type Family Practice200005572035 412128220 Fabiato, Kristin W. 2384 Colony Crossing Pl VA 231124280 Medical Doctor Endo, Diabetes & Metabolism200005593437 273479074 Richmond Urgent Care 1770 N Parham Rd Ste 100 VA 232294658 Urgent Care Services200005596133 540883363 Reinhardt, Stephen D. 3000 WATER COVE RD VA 23112 PCP Type Family Practice200005597133 540883363 Hubbard, Thomas M. 4900 Cox Rd Ste 100 VA 230606508 PCP Type Family Practice200005597503 203936773 Mahoney, Lea L. 7601 Forest Ave Ste 100 VA 232294933 PCP Type Obstetrics and Gynecology200005597739 540881356 Curtis, Dianna L. 21 HIGHLAND AVE SE # 200 VA 24013 PCP Type Obstetrics and Gynecology200005597759 541717999 Malhotra, Shailaja K. PO BOX 11768 VA 23230 PCP Type Family Practice200005602314 541717999 Breeden, Sara S. 6439 Iron Bridge Rd VA 232345205 PCP Type Family Practice200005602432 061755234 Couture, Stephen A. 1802 Braeburn Dr VA 241537357 PCP Type Internal Medicine200005603336 273069705 Schraa, Kristin P. 7130 GLEN FOREST DR # 101 VA 23226 PCP Type Obstetrics and Gynecology200005603428 383721709 Brown, Linda K. 12220 Ironbridge Rd Ste A VA 23831 PCP Type Obstetrics and Gynecology200005603478 055620549 Akbar, Salman M. 7834 Forest Hill Ave Ste 3 VA 232251974 PCP Type Internal Medicine200005603523 542019967 Ackerman, Christopher J. 203 SHARP ST VA 23868 PCP Type Internal Medicine200005603548 311716973 St Francis Family Medicine Center PO Box 6516 VA 232300516 Medical Group Family Practice200005603911 203936773 Murray, Vienne K. PO Box 79164 MD 212790164 PCP Type Obstetrics and Gynecology200005604764 273069705 Schoeffler, Edmund D. PO BOX 17670 MD 21297 PCP Type Obstetrics and Gynecology200005604869 540883363 Bedinger JR, Robert W. 7702 E Parham Road #205 VA 232944301 PCP Type Internal Medicine200005606094 541111031 Decker, Raymond G. 13911 St Francis Blvd Ste 101 VA 231143256 PCP Type Family Practice200005606981 540647482 Richmond Community Hospital Profess PO Box 6516 VA 232300516 Medical Group Internal Medicine200005607472 541586601 Kauffman, Richard D. PO Box 75394 MD 212755394 PCP Type Family Practice200005607506 273069705 Troyer, Lisa R. 5875 Bremo Rd Ste 400 VA 232261928 PCP Type Obstetrics and Gynecology200005607569 273069705 Buettner, Karin W. PO Box 17670 MD 21297 PCP Type Obstetrics and Gynecology
Franklin County, VirginiaTop Provider Report
Please indicate if these providers participate in your network by placing an "X" in the appropriate box.
PRV_ID PROVIDER_TIN Provider Name Provider Address Provider Add 2Provider State
Provider Zip Code Provider Type Provider Specialty HMO/POS PPO
Place an "X" in this column if provider is in
your HMO/POS network
Place an "X" in this column if provider is in
your PPO network
200005607684 273069705 Hutcheson, Douglas P. PO Box 17670 MD 21297 PCP Type Obstetrics and Gynecology200005607776 540890607 Phillips, Kimberly M. 9900 Independence Park Dr Ste 100 VA 232331473 PCP Type Pediatrics200005609037 541203530 Nelson, Kinloch PO Box 79437 MD 212790437 Medical Doctor Urology200005609172 273069705 Lewis, Leigh B. PO BOX 17670 MD 21297 PCP Type Obstetrics and Gynecology200005609212 561249571 Schul, Jeffery L. 7605 Forest Ave Ste 103 VA 232294936 Medical Doctor Allergy/Immunology200005609367 541910038 Turner, John W. PO BOX 36559 VA 23235 Hospitalist Pathology200005609435 541877871 Beckwith, Douglas E. 12901 Briggs Road VA 23831 PCP Type Family Practice200005610336 541910038 Kornstein, Michael J. 1605 RHOADMILLER ST VA 23220 Hospitalist Path, Anatomic and Clinical200005610342 541832508 Snowden III, Ransom G. 11601 Robious Rd Ste 100 VA 231135605 PCP Type Pediatrics200005610353 273069705 Galgano, Kimberly M. PO Box 17670 MD 212971670 PCP Type Obstetrics and Gynecology200005610367 542019967 Lawrenceville Primary Care Pc 203 SHARP ST VA 23868 Medical Group Family Practice200005610552 541744931 Williams, Carol B. 9113 Dickey Drive VA 23116 PCP Type Pediatrics200005611439 541203530 Murphy, David P. 2025 Waterside Rd Ste 105 VA 238751266 Medical Doctor Urology200005622338 540965697 Foster, James D. 9930 Independence Park Dr Ste 101 VA 232331475 PCP Type Family Practice200005626776 275493321 Medsolutions Inc 730 Cool Springs Blvd Ste 800 TN 370674641 Radiology/Xray Facility200005626905 800641696 Maraist, Adrienne L. 7605 Forest Ave Ste 411 VA 232294941 PCP Type Obstetrics and Gynecology200005638512 800721266 Farhi, Parisa 1901 S Main St Ste 1 VA 240606628 Other/Professional Ophthalmology200005649487 541832508 Allen, Konyenasoa E. 11601 Robious Rd Ste 100 VA 231135605 PCP Type Pediatrics200005716230 540506332 Riegodedios, Ricardo L. 3707 Brambleton Ave Ste 3 VA 240183658 Hospitalist Radiology, Diagnostic200005735749 050624110 Phieffer, Laura S. 420 Libbie Ave VA 232262664 Medical Doctor Dermatology200005767430 274437670 Roanoke Valley Healthcare Partners Llc 602 Brandon Ave SW Sw 222 VA 240153212 Urgent Care Services200005782944 453123110 Medexpress Urgent Care Virginia 4003 College Ave Ste B VA 246052043 Urgent Care Services200005816582 311716973 Risser, Andreya B. 13540 Hull Street Rd VA 231122107 PCP Type Family Practice200005825928 224948313 Hughes, Shawn D. 3228 Oakdale Rd VA 240183118 Social Worker Social Work200005826056 204680297 Fick, Dorene P. 2727 Electric Rd Ste 100 VA 240183500 Social Worker Social Work200005841782 272141178 Hand Cameron, April 641 Lynnhaven Pkwy Ste 204 VA 234527307 Counselor Counseling200005863061 377842308 Owen, Susan L. 1731 Grandin Rd SW VA 240152815 Social Worker Social Work200005890720 540793767 Bala, Rishi K. 9600 Patterson Ave VA 232296053 PCP Type Family Practice200005894868 541691022 Salem Vamc PO Box 19957 NC 288151957 Medical Group Internal Medicine200005906766 262047039 Hospitalist Medicine Physicians Of Virgi PO Box 740635 CA 900740635 Medical Group Internal Medicine200005915466 541744931 Lakhani, Sultan A. 1510 N 28th St Ste 101 VA 232235311 Medical Doctor Psychiatry200005921931 540506332 Hartman, David W. 213 McClanahan St SW Ste 310 VA 240141762 Medical Doctor Psychiatry200005933840 271069258 Gent, Peter C. 2621 Promenade Pkwy Ste 101 VA 231134905 PCP Type General Practice200005943986 541922588 James, Bruce M. 3712 Old Forest Rd Ste 500 VA 245016959 Counselor Counseling200005957350 542033006 Coates, Joseph B. 46 Wesley Rd VA 240833082 PCP Type Family Practice200005980316 541921600 Maguire, Clayton C. 11 Interstate Corp Center #14 VA 23502 Counselor Counseling200005998970 204680297 Allman, Jeffrey C. 2727 Electric Rd # 100 VA 24018 Social Worker Social Work200006026234 542033006 Carilion Emergency Services 4035 Electric Rd Ste A VA 240188449 Urgent Care Services200006055644 541586601 Klaus, Christian 6415 Peters Creek Rd VA 240194021 PCP Type Family Practice200006069506 540883363 Marshall, Amy K. 13332 MIDLOTHIAN TPKE VA 23113 PCP Type Family Practice200006110990 454858670 Freeman, Eric B. 9323 Midlothian Tpke Ste E VA 232354942 PCP Type Pediatrics200006197371 540897154 Bridges JR, Clifton L. 5801 Bremo Rd VA 232261907 Hospitalist Path, Anatomic and Clinical200006203783 587121784 Walker, Terri L. 207 N 4th Ave VA 238602503 Social Worker Social Work200006311422 800616231 Emergency Physicians Immediate Care 6100 Harbourside Centre Loop VA 231122170 Urgent Care Services200006345568 461239157 Smith, Stephanie E. 9137 Chamberlayne Rd Ste 107 VA 231162534 PCP Type Pediatrics200006350186 461513932 Ung, Chheany W. 441 Piney Forest Rd Ste G VA 245404154 Other/Professional Pain Medicine200006351161 461853106 Alderfer, Raymond J. 2241 Langhorne Rd VA 245011114 Psychologist Psychiatry200006372417 461886130 Bonuccelli, Brenda A. 106 N Thompson St VA 232212720 Social Worker Social Work200006389761 541453954 Augusta Medical Center 78 Medical Center Dr VA 229392332 General Hospital200006441277 541115939 Dhir, Christina D. 269 Medical Park Blvd VA 238059337 Social Worker Social Work200006455194 461593140 Al Ani, Ibtehal A. 452 Holly Farms Rd VA 239662561 PCP Type Pediatrics200006470319 540885056 Barker, Amy N. 21 Highland Ave SE Ste 100 VA 240132218 PCP Type Nurse Practitioner - Pediatric200006471432 541586601 Slayton, Russell P. Lee St Fl 1 VA 229080729 PCP Type Family Practice200006473712 043787413 Holland, Lisa A. 3507 Boulevard Ste A VA 238341319 Chiropractor Chiropractic Medicine200006501454 540881356 Grove, Margaret A. 21 Highland Ave SE Ste 200 VA 240132218 PCP Type Obstetrics and Gynecology
Franklin County, VirginiaTop Provider Report
Please indicate if these providers participate in your network by placing an "X" in the appropriate box.
PRV_ID PROVIDER_TIN Provider Name Provider Address Provider Add 2Provider State
Provider Zip Code Provider Type Provider Specialty HMO/POS PPO
Place an "X" in this column if provider is in
your HMO/POS network
Place an "X" in this column if provider is in
your PPO network
200006507878 541093643 Dean, Daniel B. 70 Medical Center Cir Ste 110 VA 229392273 Medical Doctor Surgery - Orthopedic200006517037 541634477 Hyman, Lawrence C. 2114 Hartford Rd Ste A VA 236662409 PCP Type Family Practice200009560737 541581185 Clevenger, Charles V. 1200 E Marshall St VA 232985049 Hospitalist Pathology, Anatomic200009592506 462239316 Sutherland, Tamara A. 11551 Nuckols Rd Ste F VA 230595565 PCP Type Pediatrics200009596886 463855978 Crosby, Scott J. 3960 Valley Gateway Blvd Ste A1 VA 240126859 PCP Type Family Practice200009599161 463162688 Vance, Gilbert T. 3635 Manassas Dr VA 240184031 Psychologist Psychology200009628083 061755234 Clapp, Debra H. 4231 Colonial Ave Ste 1 VA 240184046 PCP Type Obstetrics and Gynecology200009639241 541124769 Girard, Emily B. 15 Pratts Run Ste A01 VA 229806606 PCP Type Physicians Assistant200009643612 540885056 Arthur, Meredith M. PO Box 8540 VA 240140540 PCP Type Pediatrics200009654679 271672951 Good Health Express 9851 Brook Rd VA 230594559 Urgent Care Services200009659148 463395194 Emergency Physicians Immediate Care 4600 Puddledock Rd VA 238751235 Urgent Care Services200011214089 541586601 Brackenrich, Wayne L. 2145 Mount Pleasant Blvd SE VA 240143632 PCP Type Family Practice200011700095 371508496 Alliance Physical Therapy 8206 Leesburg Pke Ste 402 VA 22182 Rehab/Phys/Occup/Spch Therapy200011702190 540965697 Campbell, Michael L. 2200 Pump Rd Ste 100 VA 232333539 PCP Type Family Practice200011797370 620990097 Johnson City Urological Clinic Pc 2340 KNOB CREEK RD # 720 TN 37604 Medical Group Urology200011802602 270982413 Mdlive Medical Group Pa 13630 NW 8th St Ste 205 FL 333256238 Medical Clinic Unknown Specialty - Other200011809106 463921428 Thomas Wagoner, Licia 7501 Boulder View Dr Ste 601 VA 232254054 Social Worker Social Work200012323960 540885056 Brech II, Kilian H. 21 Highland Ave SE Ste 100 VA 240132218 PCP Type Pediatrics200012353756 561282557 Planned Parenthood Health Systems In 522 Grand Central Ave WV 261052169 Medical Group Obstetrics and Gynecology200012361131 453237812 Allman, Martha J. 611 McDowell Ave NW VA 240161225 Counselor Counseling200012366143 541472584 Thein, Khin K. 4700 Puddledock Rd Ste 300 VA 238751268 PCP Type Family Practice200012374017 541472926 Goins, Matthew D. 337 15th St SW VA 229033307 Hospitalist Anesthesiology200012376097 540794913 Smyth County Community Hospital 245 Medical Park Dr VA 24354 General Hospital200012381458 541744931 Mc Kenzie, Judith J. 8220 Meadowbridge Rd Ste 203 VA 231162339 PCP Type Internal Medicine200012451250 464735920 Yu, Lanping 648 Southpark Blvd Ste C VA 238343632 PCP Type Pediatrics200012642362 455513255 American Specialty Physical Medicine In10221 Wateridge Cir CA 921212702 Rehab/Phys/Occup/Spch Therapy200013033980 223277055 Carr, Tammy 3243 Electric Rd Ste 2B VA 240186440 Counselor Counseling200015587453 540506331 Sentara Rmh Medical Center 2010 Health Campus Dr VA 228018679 General Hospital200015913398 231067614 Anderson, Jordana M. 20 Walnut Ave SW VA 240164719 Social Worker Social Work200016688785 541905361 Desai, Jitendra S. 16 Walnut Ave SW VA 240164719 Medical Doctor Psychiatry200016805755 541924866 Southern Virginia Regional Medical Cen727 N Main St VA 238471274 General Hospital200017671887 540793767 Asad, Ismat A. 2600 E Parham Rd VA 232282932 PCP Type Family Practice200018879686 562070036 Duke University Hospital 2301 Erwin Rd NC 277054699 General Hospital200021022735 273069705 Vaclavik, Alex C. 5875 Bremo Rd Ste 400 VA 232261928 PCP Type Obstetrics and Gynecology200021752881 320417652 The Little Clinic Of Va Llc PO Box 932958 OH 44193 PCP Type Family Practice200022996584 540965697 Gooss Iv, Lawrence W. 14415 Justice Rd Ste 1 VA 231136908 PCP Type Family Practice200025588666 541124769 Gorham, James D. Hospital Dr VA 229080001 Hospitalist Pathology200026041149 541586601 Kinsey, Adrienne M. 1818 Electric Rd VA 240181619 PCP Type Internal Medicine200026735695 800641696 Weatherford, Shannon R. 7603 Forest Ave Ste 403 VA 232294944 PCP Type Obstetrics and Gynecology200026735806 202265068 Watterson, William K. 1401 Johnston Willis Dr VA 232354730 PCP Type Internal Medicine200026736250 202265068 Dodd, Jeffrey D. 2891 Anderson Hwy VA 231397406 PCP Type Family Practice200026736293 800641696 Ramsey, Tiffany S. 7601 Forest Ave Ste 228 VA 232294933 PCP Type Obstetrics and Gynecology200026893016 800641696 Clary Iii, Beverley B. 7601 Forest Ave Ste 228 VA 232294933 PCP Type Obstetrics and Gynecology200028441210 541794094 Hagan, Charlotte 4461 Starkey Rd Ste 201 VA 240180622 Medical Doctor Psychiatry200028762656 473700042 Parker, Erika A. 605 Twinridge Ln VA 23235 Other/Professional Psychology200031202042 540568001 Carilion Stonewall Jackson Hospital 1 Health Cir VA 244502448 General Hospital200031303007 540885859 Orthovirginia Inc 1115 Boulders Pkwy Ste 100 VA 232254067 Medical Group Surgery - Orthopedic200031761656 621113733 Henrico Doctors Hospital 1602 Skipwith Rd VA 232295205 General Hospital200032244873 541586601 Tanner, William J. 415 S Pollard St VA 241792502 PCP Type Family Practice200032280098 541001246 Ashby, Molly E. 5875 Bremo Rd Ste 201 VA 232261934 PCP Type Obstetrics and Gynecology200034706126 541217184 Husen, Srie D. 11803 Jefferson Ave Ste 100 VA 236064390 PCP Type Family Practice200035152522 271444665 Garwood, Robert A. 2006 Health Campus Dr VA 228018679 Medical Doctor Surgery - General200036284231 541760584 Bills, Heath J. 3536 Grove Ave VA 232212200 Chiropractor Chiropractic Medicine200036650512 272236579 Veldman, Linda 277 Hydraulic Ridge Rd VA 22901 Occupational Therapist Therapy - Occupational200036693480 541549651 Cannon, Shannon J. 6510 Harbour View Ct Ste 100 VA 231126559 PCP Type Nurse Practitioner - Pediatric
Franklin County, VirginiaTop Provider Report
Please indicate if these providers participate in your network by placing an "X" in the appropriate box.
PRV_ID PROVIDER_TIN Provider Name Provider Address Provider Add 2Provider State
Provider Zip Code Provider Type Provider Specialty HMO/POS PPO
Place an "X" in this column if provider is in
your HMO/POS network
Place an "X" in this column if provider is in
your PPO network
200036757330 203575038 Aldredge, Patricia R. 2510 Gaskins Rd VA 232381481 PCP Type Nurse - Practitioner200036760877 202265068 Bailey, Jordan 2410 Pagehurst Dr VA 231136411 PCP Type Nurse Practitioner - Family Pr200036762802 542021508 Dales, Danny J. 111-A Sanders Ln VA 24605 Chiropractor Chiropractic Medicine200036763896 621098942 Manning, Anthony P. 5801 Bremo Rd VA 232261907 Hospitalist Anesthesiology200036885521 202265068 Marsh, John O. 771 Steeles Fort Rd VA 244722501 PCP Type Family Practice200036989319 540793767 Haithcock, Roderick E. 505 W Leigh St Ste 303 VA 232203248 PCP Type Internal Medicine200037122747 461553034 Andrews, Daniel A. 901 McDonough St VA 232242282 Chiropractor Chiropractic Medicine200037421833 541481593 Frear, Vivian T. 410 Foulk Rd Ste 105 DE 198033835 Counselor Counseling200037475348 841699629 Rpn Of Va Inc PO Box 633491 OH 452633491 Rehab/Phys/Occup/Spch Therapy200037483732 542025695 Foresman, Ashley Marie M. 15521 Midlothian Tpke Ste 105 VA 231137313 Psychologist Psychology200037525197 810701822 Zoppetti, Lisa A. 5206 Markel Rd Ste 104 VA 232303044 Psychologist Psychology200037671990 541364028 Medical Imaging Of Fredericksburg Llc 1101 Sam Perry Blvd Ste 115 VA 224014465 Radiology/Xray Facility200037890846 540885859 Reece, Steven G. 13801 St Francis Blvd Ste 200 VA 231143206 Other/Professional Sports Medicine200038102350 300857312 Thacker, Sarah L. 1900 Byrd Ave Ste 200 VA 232303033 Counselor Counseling200038427058 541816181 Iskandar, Joseph W. 5372 Fallowater Ln Ste C VA 240180950 Medical Doctor Psychiatry200038914124 540883363 Ng, Charlene 6900 Forest Ave Ste 300 VA 232301730 PCP Type Family Practice200038932577 473530487 Roanoke Physician Services Llc 5665 New Northside Dr Ste 320 GA 303285834 Medical Group Emergency Medicine200038989027 061755234 Coartney, Sierra D. 1802 Braeburn Dr VA 241537357 PCP Type Pediatrics200039187174 541832508 Jones, Christine S. 11601 Robious Rd Ste 100 VA 231135605 PCP Type Pediatrics200039332258 800686939 Md Labs 10715 Double R Blvd Ste 102 NV 895218970 Laboratory200039393214 430738490 Ssm Health Cardinal Glennon Childrens 1465 S Grand Blvd MO 631041003 General Hospital200039425420 541001246 Washington, Monica M. 1630 Wilkes Ridge Pkwy Ste 200 VA 232337460 PCP Type Obstetrics and Gynecology200040274746 202265068 Dodd, Jarrett S. 14005 Wards Rd Ste A VA 245017127 PCP Type Family Practice200040275298 540890607 Rusin, Molly M. 7521 Right Flank Rd Ste 100 VA 231163871 PCP Type Pediatrics200040529950 202265068 Haupricht Jr, Bradley J. 1971 University Blvd Ste 1895 VA 245150002 PCP Type Family Practice200040540263 202265068 Kleiner, Mark A. 131 Jones St VA 245229830 PCP Type Family Practice200040574017 273069705 Conner, Cathleen M. 5875 Bremo Rd Ste 400 VA 232261928 Nurse Practitioner Women's Hlth NP200040729615 541581185 Gomes, Denese C. 1200 E Broad St VA 232985058 PCP Type Nurse - Practitioner200040755268 421560723 Petrizzi, Mark G. 8266 Atlee Rd Ste 226 VA 231161806 PCP Type Family Practice200040783060 202265068 Albers, Gregg R. 2811 Linkhorne Dr Ste A VA 245033354 PCP Type Family Practice200041027474 475048215 Elton, Nicole 3247 Electric Rd Ste 1A VA 240186448 Social Worker Social Work200041027885 541669672 Patient First Richmond Physicians Grou 14800 Lee Hwy VA 201551842 Urgent Care Services Urgent Care200041030118 540883363 Litos, Martha T. 7255 Hanover Green Dr VA 231111706 PCP Type Family Practice200041237664 465219452 True Health Diagnostics PO Box 205391 TX 75320 Laboratory200041683141 202265068 Michie, David W. 306 E 6th Ave VA 239442050 PCP Type Family Practice200041691931 542025695 Tate, Amber 9202 Center Oak Ct VA 231162744 Counselor Counseling200041745596 540506332 Mullet, James G. 1 Health Cir VA 244502448 Hospitalist Radiology, Diagnostic200041753044 540506332 Dittrich, Karen A. 141 Ben Bolt Ave VA 246519700 Hospitalist Radiology, Diagnostic200041753185 540506332 Johnsen, David E. 800 Oak St VA 239011199 Hospitalist Radiology, Diagnostic200041753246 540506332 Carmouche, Jonathan J. 2900 Lamb Cir Ste 380 VA 240736345 Medical Doctor Surgery - Orthopedic200041753271 540506332 Mc Lennan, Lee A. 213 McClanahan St SW Ste 110 VA 240141762 PCP Type Obstetrics and Gynecology200041753314 540506332 Garcia, Jorge M. 150 Market Ridge Ln VA 240833258 PCP Type Obstetrics and Gynecology200041753316 540506332 Sullivan, Christopher M. 102 Highland Ave SE Ste 303 VA 240132253 PCP Type Obstetrics and Gynecology200041765270 540506332 Lara Torre, Eduardo 902 S Jefferson St VA 240164404 PCP Type Obstetrics and Gynecology200041765398 540506332 Fakharzadeh, Benjamin B. 1 Health Cir VA 244502448 Medical Doctor Radiology, Diagnostic200041771220 540506332 Sherigar, Rathnakar M. 1906 Belleview Ave SE VA 240141838 Radiologist Radiology200041805487 540506332 Olazagasti, Juan C. 1107B Brookdale St VA 241124501 Medical Doctor Pediatric Gastroenterology200042053361 541603376 Lukhard, Sarah 9020 Stony Point Pkwy Ste 240 VA 232351980 Counselor Counseling200042110326 541417686 Bon Secours Imaging Center At Innsbro 4900 Cox Rd Ste 100 VA 230606508 Radiology/Xray Facility200042286830 273851927 Singh, Jaspreet 324 Commerce Rd Ste A VA 239012794 Medical Doctor Cardiovascular Disease200042419021 463521146 Duke, Susan 603 Jefferson Davis Hwy Ste 101 VA 224014565 Counselor Counseling200042695104 464242807 James River Emergency Group Llc 7101 Jahnke Rd VA 232254017 Medical Group Emergency Medicine200042695110 464242807 James River Emergency Group Llc 7101 Jahnke Rd VA 232254017 Medical Group Emergency Medicine200042695111 464242807 James River Emergency Group Llc 7101 Jahnke Rd VA 232254017 Medical Group Emergency Medicine200042840806 541762441 Parisi, Richard A. 7650 E Parham Rd Ste 220 VA 232944367 Medical Doctor Pulmonary Disease
Franklin County, VirginiaTop Provider Report
Please indicate if these providers participate in your network by placing an "X" in the appropriate box.
PRV_ID PROVIDER_TIN Provider Name Provider Address Provider Add 2Provider State
Provider Zip Code Provider Type Provider Specialty HMO/POS PPO
Place an "X" in this column if provider is in
your HMO/POS network
Place an "X" in this column if provider is in
your PPO network
200043054682 540506332 Liebesny, Katherine 2017 S Jefferson St VA 240142419 Medical Doctor Psychiatry200043072463 313024346 Walden, Jeremy T. 8134 Old Keene Mill Rd Ste 101 VA 221521849 Psychologist Psychology
This will be provided separately when the listing becomes available.
Franklin County, VirginiaRx Checklist
No. NDC Brand Name NDC Tier 1 Tier 2 Tier 3 Tier 4
Mark an "X" in the appropriate tier column
This will be provided separately when the listing becomes available.
Option 1: Current Plans
Franklin County effective July 1, 2020
Name of Offeror: Specific Reinsurance Limit: $125,000Plans Quoted This Exhibit: Aggregate Reinsurance Limit: 120%
Quote Includes (Medical, Rx, Both): Reinsurance Basis (12/18, 12/15, 12/12, etc.): 12/18
Enrollment Assumptions:
Employee onlyEmployee + child
Employee + childrenEmployee + spouseEmployee + family
TotalDescription of Plan:
Medical Rx Medical Rx Medical Rx Medical RxGross projected claimsNetwork savingsNet fee-for-service claimsCapitation expenses
Total Claims Expense $0 $0 $0 $0 $0 $0 $0 $0Specific stop loss feesAggregate stop loss fees
Total Reinsurance Fees $0 $0 $0 $0 $0 $0 $0 $0Administrative expensesRx Rebate creditNetwork access feesUtilization review feesConversion chargesOther retention expenses
Total Retention Expenses $0 $0 $0 $0 $0 $0 $0 $0Total Projected Cost $0 $0 $0 $0 $0 $0 $0 $0
Projected Maximum Cost
PPO High Option ($500 ded/$15/20%)Employees Estimated Members
26
101
31
26
405
41
First Year Mature YearPPO High Option ($500 ded/$15/20%) PPO Low Option ($1,000 ded/$20/20%)
First Year Mature Year
283 582
PPO Low Option ($1,000 ded/$20/20%)Estimated Members
120
13274
Employees120
413743
3 42 846
172
Use this spreadsheet for the self-funded quote for the CURRENT plan design.
coh/2003medrfp/Attachments - Franklin County RFP.xlsx/E1 Underwriting Current/10/30/2019
Option 2: Alternative Plans
Franklin County effective July 1, 2020
Name of Offeror: Specific Reinsurance Limit: $125,000Plans Quoted This Exhibit: Aggregate Reinsurance Limit: 120%
Quote Includes (Medical, Rx, Both): Reinsurance Basis (12/18, 12/15, 12/12, etc.): 12/18
Enrollment Assumptions:
Employee onlyEmployee + child
Employee + childrenEmployee + spouseEmployee + family
TotalDescription of Plan:
Medical Rx Medical Rx Medical Rx Medical RxGross projected claimsNetwork savingsNet fee-for-service claimsCapitation expenses
Total Claims Expense $0 $0 $0 $0 $0 $0 $0 $0Specific stop loss feesAggregate stop loss fees
Total Reinsurance Fees $0 $0 $0 $0 $0 $0 $0 $0Administrative expensesRx Rebate creditNetwork access feesUtilization review feesConversion chargesOther retention expenses
Total Retention Expenses $0 $0 $0 $0 $0 $0 $0 $0Total Projected Cost $0 $0 $0 $0 $0 $0 $0 $0
Projected Maximum Cost
PPO High Option ($500 ded/$15/20%) Low Option HDHP ($3,500 ded/20%)Employees Estimated Members Employees Estimated Members
117 117 29 29
34 109 8 2736 72 9 18
30 59 7 1535 142 9 35
251 498 63 125PPO High Option ($500 ded/$15/20%) Low Option HDHP ($3,500 ded/20%)
First Year Mature Year First Year Mature Year
Use this spreadsheet for the self-funded quote for the ALTERNATE plan design.
coh/2003medrfp/Attachments - Franklin County RFP.xlsx/E1 Underwriting Alternative/10/30/2019
Option 1: Current Plans
Franklin County effective July 1, 2020
Name of Offeror: 0 Specific Reinsurance Limit: $125,000Plans Quoted This Exhibit: 0 Aggregate Reinsurance Limit: 120%
Quote Includes (Medical, Rx, Both): 0 Reinsurance Basis (12/18, 12/15, 12/12, etc.): 12/18
Enrollment Assumptions:
Employee onlyEmployee + child
Employee + childrenEmployee + spouseEmployee + family
TotalDescription of Plan:
Medical RX Medical RX Medical RX Medical RXEXPRESS ALL CHARGES AND FEES ON A PER EMPLOYEE PER MONTH BASIS
Net fee-for-service Claims PEPMCapitation expenses PEPM
Total Claims Expense PEPM $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Specific Stop Loss fees PEPMAggregate Stop Loss fees PEPM
Total Reinsurance fees PEPM $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Administrative expenses PEPMRx Rebate creditNetwork access fees PEPMUtilization review fees PEPMConversion charges PEPMOther retention expenses PEPM
Total Retention expenses PEPM $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
26 26 120 120Employees Estimated Members Employees Estimated Members
PPO High Option ($500 ded/$15/20%)
PPO High Option ($500 ded/$15/20%) PPO Low Option ($1,000 ded/$20/20%)
PPO Low Option ($1,000 ded/$20/20%)
First Year Mature Year First Year Mature Year
1 5 43 17231 41
3 6 42 84
For ALL capitation, reinsurance and retention expenses, list the charges/fees as they will appear in the contract and explain how the costs will be calculated and charged
283 582
1 4 41 1320 0 37 74
Use this spreadsheet for the self-funded quote for the CURRENT plan design.
C:\Users\cat\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\U1DCIT5B\Attachments - Franklin County RFP.xlsx
Option 2: Alternative Plans
Franklin County effective July 1, 2020
Name of Offeror: 0 Specific Reinsurance Limit: $125,000Plans Quoted This Exhibit: 0 Aggregate Reinsurance Limit: 120%
Quote Includes (Medical, Rx, Both): 0 Reinsurance Basis (12/18, 12/15, 12/12, etc.): 12/18
Enrollment Assumptions:
Employee onlyEmployee + child
Employee + childrenEmployee + spouseEmployee + family
TotalDescription of Plan:
Medical RX Medical RX Medical RX Medical RXEXPRESS ALL CHARGES AND FEES ON A PER EMPLOYEE PER MONTH BASIS
Net fee-for-service Claims PEPMCapitation expenses PEPM
Total Claims Expense PEPM $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Specific Stop Loss fees PEPMAggregate Stop Loss fees PEPM
Total Reinsurance fees PEPM $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00Administrative expenses PEPMRx Rebate creditNetwork access fees PEPMUtilization review fees PEPMConversion charges PEPMOther retention expenses PEPM
Total Retention expenses PEPM $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
PPO High Option ($500 ded/$15/20%) Low Option HDHP ($3,500 ded/20%)Employees Estimated Members Employees Estimated Members
117 117 29 29
34 109 8 2736 72 9 18
30 59 7 1535 142 9 35
251 498 63 125PPO High Option ($500 ded/$15/20%) Low Option HDHP ($3,500 ded/20%)First Year Mature Year First Year Mature Year
For ALL capitation, reinsurance and retention expenses, list the charges/fees as they will appear in the contract and explain how the costs will be calculated and charged
Use this spreadsheet for the self-funded quote for the ALTERNATE plan design.
C:\Users\cat\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\U1DCIT5B\Attachments - Franklin County RFP.xlsx
C:\Users\cat\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\U1DCIT5B\Attachments - Franklin County RFP.xlsx
Option 1: Current Plans
Franklin County effective July 1, 2020
Name of Offeror: 0 Specific Reinsurance Limit: $125,000Plans Quoted This Exhibit: 0 Aggregate Reinsurance Limit: 120%
Quote Includes (Medical, Rx, Both): 0 Reinsurance Basis (12/18, 12/15, 12/12, etc.): 12/18
Enrollment AssumptionsEmployee only
Employee + childEmployee + childrenEmployee + spouseEmployee + family
Total
Medical RX Medical RX Medical RX Medical RXEmployee only
Employee + childEmployee + childrenEmployee + spouseEmployee + familyAnnual Premium $0 $0 $0 $0 $0 $0 $0 $0
Medical RX Medical RX Medical RX Medical RXEmployee only
Employee + childEmployee + childrenEmployee + spouseEmployee + familyAnnual Premium $0 $0 $0 $0 $0 $0 $0 $0
26 120
1 41
Mature Year
PPO High Option ($500 ded/$15/20%)
Expected Liability RatesFirst Year Mature Year First Year
PPO Low Option ($1,000 ded/$20/20%)
31 283
0 371 43
3 42
Maximum Liability RatesFirst Year Mature Year First Year Mature Year
Use this spreadsheet for the self-funded quote for the CURRENT plan design. Also show the rates for the CURRENT plan design on a fully-insured basis at the
bottom of the worksheet.
C:\Users\cat\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\U1DCIT5B\Attachments - Franklin County RFP.xlsx
Option 2: Alternative Plans
Franklin County effective July 1, 2020
Name of Offeror: 0 Specific Reinsurance Limit: $125,000Plans Quoted This Exhibit: 0 Aggregate Reinsurance Limit: 120%
Quote Includes (Medical, Rx, Both): 0 Reinsurance Basis (12/18, 12/15, 12/12, etc.): 12/18
Enrollment AssumptionsEmployee only
Employee + childEmployee + childrenEmployee + spouseEmployee + family
Total
Medical RX Medical RX Medical RX Medical RXEmployee only
Employee + childEmployee + childrenEmployee + spouseEmployee + familyAnnual Premium $0 $0 $0 $0 $0 $0 $0 $0
Medical RX Medical RX Medical RX Medical RXEmployee only
Employee + childEmployee + childrenEmployee + spouseEmployee + familyAnnual Premium $0 $0 $0 $0 $0 $0 $0 $0
34 8
PPO High Option ($500 ded/$15/20%) Low Option HDHP ($3,500 ded/20%)117 2936 9
30 735 9
251 63
Expected Liability RatesFirst Year Mature Year First Year Mature Year
Maximum Liability RatesFirst Year Mature Year First Year Mature Year
Use this spreadsheet for the self-funded quote for the ALTERNATE plan design. Also show the rates for the ALTERNATE plan design on a fully-insured basis at the
bottom of the worksheet.
C:\Users\cat\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\U1DCIT5B\Attachments - Franklin County RFP.xlsx
Option 1: Current Plans
Franklin County effective July 1, 2020
Name of Offeror: 0Plans Quoted This Exhibit: 0
Quote Includes (Medical, Rx, Both): 0
Outline Underwriting Assumptions and Deviations:
coh/medrfp2003/Attachments - Franklin County RFP.xlsx/E4 UW Assumptions Current/10/30/2019
Option 2: Alternative Plans
Franklin County effective July 1, 2020
Name of Offeror: 0Plans Quoted This Exhibit: 0
Quote Includes (Medical, Rx, Both): 0
Outline Underwriting Assumptions and Deviations:
coh/medrfp2003/Attachments - Franklin County RFP.xlsx/E4 UW Assumptions Alternative/10/30/2019