Exhibit 10.1

NINTH AMENDMENT TO

MANAGED CARE ALLIANCE AGREEMENT

THIS NINTH AMENDMENT (the “Amendment”) is entered into this 4th day of February,
2008 by and between CIGNA Health Corporation, for and on behalf of its CIGNA
Affiliates (individually and collectively, “CIGNA”) and Gentiva CareCentrix,
Inc. (“MCA”).

WITNESSETH

WHEREAS, CIGNA and MCA entered into a Managed Care Alliance Agreement which
became effective January 1, 2004, as amended from time to time, (the
“Agreement”) whereby MCA agreed to provide or arrange for the provision of
certain home health care services to Participants, as that term is defined in
the Agreement;

WHEREAS, the parties wish to amend the Agreement to extend the term of the
Agreement and to change the capitation service rates and other designated fee
for service rates effective February 1, 2008 and to include such other terms and
conditions as set forth in this Amendment.

NOW THEREFORE, CIGNA and MCA agree to amend the Agreement as follows:

 

  1. This Ninth Amendment shall be effective on February 1, 2008 for services
rendered on and after February 1, 2008.

  2. Section III.B. of the Agreement is amended to extend the term of the
Agreement until January 31, 2011 and is replaced to read as follows:

“Term of Agreement

This Agreement shall terminate on January 31, 2011. Either party may elect not
to renew this Agreement by providing at least ninety (90) days advance written
notice to the other party, prior to the termination date of this Agreement. If
neither party exercises such right to terminate, the existing rates will remain
in place and this Agreement shall automatically renew for consecutive one
(1) year terms without any further action by either party, unless either party
elects not to renew this Agreement by providing at least ninety (90) days
advance written notice to the other party, prior to the commencement of the next
term.

Notwithstanding the expiration or non-renewal of this Agreement pursuant to this
Section B., this Agreement shall continue in effect with respect to those Payors
covered under Service Agreements in effect as of the end of the term of this
Agreement or the notice period, as applicable, but not to exceed twelve months
from the effective date of termination or expiration.”

 

  3. The notice provision of the agreement, entitled “Notice”, is hereby deleted
in its entirety and replaced with the new Section III.K. as follows:

“Any notice required hereunder shall be in writing and shall be sent by United
States mail, postage prepaid, to CIGNA and MCA at the addresses set forth below:

 

1

--------------------------------------------------------------------------------

If to MCA:

Senior Vice President

CareCentrix

3 Huntington Quadrangle 200S

Melville, NY 11747

and:

General Counsel

Gentiva Health Services, Inc.

3 Huntington Quadrangle 200S

Melville, NY 11747

If to CIGNA:

CIGNA HealthCare

National Contracting

900 Cottage Grove Road, B7NC

Hartford, CT 06152

and:

CIGNA HealthCare

Legal Department

900 Cottage Grove Road, B6LPA

Hartford, CT 06152”

 

  4. Exhibit A HMO Program Attachment – Capitation Schedule of Capitation Rates
is hereby deleted in its entirety and replaced with a new Exhibit A HMO Program
Attachment – Capitation Schedule of Capitation Rates attached hereto for
services provided on and after February 1, 2008.

 

  5. Exhibit A HMO Program Attachment – Fee for Service Reimbursement For Other
Services is hereby deleted in its entirety and replaced with a new Exhibit A HMO
Program Attachment – Fee for Service Reimbursement For Other Services attached
hereto for services provided on and after February 1, 2008.

 

  6. Exhibit A Gatekeeper Program Attachment – Capitation Schedule of Capitation
Rates is hereby deleted in its entirety and replaced with a new Exhibit A
Gatekeeper Program Attachment – Capitation Schedule of Capitation Rates attached
hereto for services provided on and after February 1, 2008

 

  7. Exhibit A Gatekeeper Program Attachment – Fee for Service Reimbursement For
Other Services is hereby deleted in its entirety and replaced with a new Exhibit
A Gatekeeper Program Attachment – Fee for Service Reimbursement For Other
Services attached hereto for services provided on and after February 1, 2008.

 

  8. Exhibit A PPO & Indemnity Program Attachment – Fee for Service
Reimbursement For Other Services is hereby deleted in its entirety and replaced
with a new Exhibit A PPO & Indemnity Program Attachment Reimbursement For Other
Services attached hereto for services provided on and after February 1, 2008.

 

2

--------------------------------------------------------------------------------

  9. CIGNA and MCA agree to the following additional terms:

 

  a) ***

 

  b) ***

 

  c) ***

 

  d) ***

 

  e) MCA will submit, by May 1, 2008, a fee schedule at code level detail to be
used for CIGNA audit purposes. The Agreement will be amended at that time, if
necessary, to make changes to the Agreement to address any issues identified
through such review;

 

  f) The parties will collaborate to create, by May 1, 2008, a summary report
showing CAP and fee-for-service detail specific to products and geographic
locations. The Agreement will be amended at that time, if necessary, to make
changes to the Agreement to address any issues identified through such review;

 

  g) ***

 

*** Confidential Treatment Requested.

 

3

--------------------------------------------------------------------------------

  10. To the extent that the provisions in the Agreement, including any prior
amendments, conflict with the terms of this Amendment (including the exhibits
and schedules hereto), the terms in this Amendment shall supersede and control.
All other terms and conditions of the Agreement, including the Program
Attachments and the Exhibits attached thereto, shall remain the same and in full
force and effect. Capitalized terms not defined herein but defined in the
Agreement shall have the same meaning as defined in the Agreement.

IN WITNESS WHEREOF, CIGNA and MCA have caused their duly authorized
representatives to execute this Amendment as of the date first written above.

 

CIGNA HEALTH CORPORATION By:  

/s/ Joseph E. Turgeon, III,

Its:   VP Network Strategy & Development Dated:   February 5, 2008 GENTIVA
CARECENTRIX, INC. By:  

/s/ Thomas Boelsen

Its:   Sr. V.P Dated:   February 4, 2008

 

4

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EXHIBIT A

HMO PROGRAM ATTACHMENT - CAPITATION

SCHEDULE OF CAPITATION RATES

CAPITATION RATES EFFECTIVE 2/1/08 - 1/31/09

These are the capitation rates that apply to services rendered to Patient Panel
Participants enrolled in HMO Programs. An “HMO Program” means a
non-governmental, fully insured HMO or Point of Service product that is
underwritten based on a community rating methodology (i.e. community rating,
community rating by class, adjusted community rating by class).

 

     CareCentrix
Home Health,
Infusion, DME/
HME
Capitation Rates
PMPM

All Commercial HMO Program Capitated Affiliates

   ***

Capitation Rate Compensation Terms

The following rates are established for the provision of Home Care Services
rendered to Program Participants covered under the HMO and Gatekeeper plans:

 

February 1, 2008 - January 31, 2009    *** per member per month February 1, 2009
- January 31, 2010    *** per member per month February 1, 2010 - January 31,
2011    *** per member per month

The capitation rate listed above will be allocated between HMO and Gatekeeper
Program particiants in accordance with established business practices. On or
about February 1 of each year, the parties shall reconcile the allocation and
settle any payment difference no later than February 28 of each calendar year.

If an outlier calcuation for *** demonstrates a patient per thousand (PPK)
increase in excess of ***, (***), then MCA reserves the right to propose an ***
pmpm outlier adjustment. CIGNA may elect to accept this adjustment or *** and
*** from this agreement.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

EXHIBIT A

HMO PROGRAM ATTACHMENT - FEE FOR SERVICE

REIMBURSEMENT FOR OTHER SERVICES

RATE AREA DESIGNATIONS:

 

STATE

 

RATE AREA

 

RATE DESIGNATION

Alabama

  ***   ***

Alaska

  ***   ***

Arizona

  ***   ***

Arkansas

  ***   ***

California

  ***   ***

Colorado

  ***   ***

Connecticut

  ***   ***

Delaware

  ***   ***

District of Columbia

  ***   ***

Florida

  ***   ***

Georgia

  ***   ***

Hawaii

  ***   ***

Idaho

  ***   ***

Illinois

  ***   ***

Indiana

  ***   ***

Iowa

  ***   ***

Kansas

  ***   ***

Kentucky

  ***   ***

Louisiana

  ***   ***

Maine

  ***   ***

Maryland

  ***   ***

Massachusetts

  ***   ***

Michigan

  ***   ***

Minnesota

  ***   ***

Mississippi

  ***   ***

Missouri

  ***   ***

Montana

  ***   ***

Nebraska

  ***   ***

Nevada

  ***   ***

New Hampshire

  ***   ***

New Jersey

  ***   ***

New Mexico

  ***   ***

New York

  ***   ***

North Carolina

  ***   ***

North Dakota

  ***   ***

Ohio

  ***   ***

Oklahoma

  ***   ***

Oregon

  ***   ***

Pennsylvania

  ***   ***

Rhode Island

  ***   ***

South Carolina

  ***   ***

South Dakota

  ***   ***

Tennessee

  ***   ***

Texas

  ***   ***

Utah

  ***   ***

Vermont

  ***   ***

Virginia

  ***   ***

Washington

  ***   ***

West Virginia

  ***   ***

Wisconsin

  ***   ***

Wyoming

  ***   ***

 

*** Confidential Treatment Requested

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

HMO RATES EFFECTIVE FEBRUARY 1, 2008 - JANUARY 31, 2009

The following Traditional Home Health Services have both Visit and Hourly rates.

 

Notes 1, 2, 3, 4, 5 and 6 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

CERTIFIED NURSES AIDE

   ***   ***   ***   ***   ***   ***

HOME HEALTH AIDE

   ***   ***   ***   ***   ***   ***

LVN/LPN

   ***   ***   ***   ***   ***   ***

LVN/LPN - HIGH TECH

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH RN

   ***   ***   ***   ***   ***   ***

PEDIATRIC LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC RN

   ***   ***   ***   ***   ***   ***

RN

   ***   ***   ***   ***   ***   ***

RN HIGH TECH INFUSION

   ***   ***   ***   ***   ***   ***

RN HIGH TECH OTHER

   ***   ***   ***   ***   ***   *** The following Traditional Home Health
Services have Visit only rates.

Notes 1, 3, 4, 5, 7 and 8 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

DIABETIC NURSE

   ***   N/A   ***   N/A   ***   N/A

DIETITIAN

   ***   N/A   ***   N/A   ***   N/A

ENTEROSTOMAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

MATERNAL CHILD HEALTH

   ***   N/A   ***   N/A   ***   N/A

MEDICAL SOCIAL WORKER

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PHLEBOTOMIST

   ***   N/A   ***   N/A   ***   N/A

PHOTOTHERAPY PACKAGE SERVICE

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PSYCHIATRIC NURSE

   ***   N/A   ***   N/A   ***   N/A

REHABILITATION NURSE

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST

   ***   N/A   ***   N/A   ***   N/A

RN ASSESSMENT, INITIAL

   ***   N/A   ***   N/A   ***   N/A

RN SKILLED NURSING VISIT-EXTENSIVE

   ***   N/A   ***   N/A   ***   N/A

SPEECH THERAPIST

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—RN

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—LVN/LPN

   ***   N/A   ***   N/A   ***   N/A The following Traditional Home Health
Service has Hourly only rates.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

HOMEMAKER

   N/A   ***   N/A   ***   N/A   *** The following Traditional Home Health
Service is priced on a Per Diem basis.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3        Per
Diem       Per
Diem       Per
Diem

COMPANION/LIVE IN

     ***     ***     ***

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

HMO RATES EFFECTIVE FEBRUARY 1, 2009 - JANUARY 31, 2010

The following Traditional Home Health Services have both Visit and Hourly rates.

 

Notes 1, 2, 3, 4, 5 and 6 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

CERTIFIED NURSES AIDE

   ***   ***   ***   ***   ***   ***

HOME HEALTH AIDE

   ***   ***   ***   ***   ***   ***

LVN/LPN

   ***   ***   ***   ***   ***   ***

LVN/LPN - HIGH TECH

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH RN

   ***   ***   ***   ***   ***   ***

PEDIATRIC LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC RN

   ***   ***   ***   ***   ***   ***

RN

   ***   ***   ***   ***   ***   ***

RN HIGH TECH INFUSION

   ***   ***   ***   ***   ***   ***

RN HIGH TECH OTHER

   ***   ***   ***   ***   ***   *** The following Traditional Home Health
Services have Visit only rates.

Notes 1, 3, 4, 5, 7 and 8 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

DIABETIC NURSE

   ***   N/A   ***   N/A   ***   N/A

DIETITIAN

   ***   N/A   ***   N/A   ***   N/A

ENTEROSTOMAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

MATERNAL CHILD HEALTH

   ***   N/A   ***   N/A   ***   N/A

MEDICAL SOCIAL WORKER

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PHLEBOTOMIST

   ***   N/A   ***   N/A   ***   N/A

PHOTOTHERAPY PACKAGE SERVICE

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PSYCHIATRIC NURSE

   ***   N/A   ***   N/A   ***   N/A

REHABILITATION NURSE

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST

   ***   N/A   ***   N/A   ***   N/A

RN ASSESSMENT, INITIAL

   ***   N/A   ***   N/A   ***   N/A

RN SKILLED NURSING VISIT-EXTENSIVE

   ***   N/A   ***   N/A   ***   N/A

SPEECH THERAPIST

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—RN

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—LVN/LPN

   ***   N/A   ***   N/A   ***   N/A The following Traditional Home Health
Service has Hourly only rates.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

HOMEMAKER

   N/A   ***   N/A   ***   N/A   *** The following Traditional Home Health
Service is priced on a Per Diem basis.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3        Per
Diem       Per
Diem       Per
Diem

COMPANION/LIVE IN

     ***     ***     ***

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

HMO RATES EFFECTIVE FEBRUARY 1, 2010 - JANUARY 31. 2011

The following Traditional Home Health Services have both Visit and Hourly rates.

 

Notes 1, 2, 3, 4, 5 and 6 apply

   Area 1     Area 2     Area 3      Visit   Hour     Visit   Hour     Visit  
Hour  

CERTIFIED NURSES AIDE

   ***   ***     ***   ***     ***   ***  

HOME HEALTH AIDE

   ***   ***     ***   ***     ***   ***  

LVN/LPN

   ***   ***     ***   ***     ***   ***  

LVN/LPN - HIGH TECH

   ***   ***     ***   ***     ***   ***  

PEDIATRIC HIGH TECH LVN/LPN

   ***   ***     ***   ***     ***   ***  

PEDIATRIC HIGH TECH RN

   ***   ***     ***   ***     ***   ***  

PEDIATRIC LVN/LPN

   ***   ***     ***   ***     ***   ***  

PEDIATRIC RN

   ***   ***     ***   ***     ***   ***  

RN

   ***   ***     ***   ***     ***   ***  

RN HIGH TECH INFUSION

   ***   ***     ***   ***     ***   ***  

RN HIGH TECH OTHER

   ***   ***     ***   ***     ***   ***   The following Traditional Home Health
Services have Visit only rates.  

Notes 1, 3, 4, 5, 7 and 8 apply

   Area 1     Area 2     Area 3      Visit   Hour     Visit   Hour     Visit  
Hour  

DIABETIC NURSE

   ***   N/A     ***   N/A     ***   N/A  

DIETITIAN

   ***   N/A     ***   N/A     ***   N/A  

ENTEROSTOMAL THERAPIST

   ***   N/A     ***   N/A     ***   N/A  

MATERNAL CHILD HEALTH

   ***   N/A     ***   N/A     ***   N/A  

MEDICAL SOCIAL WORKER

   ***   N/A     ***   N/A     ***   N/A  

OCCUPATIONAL THERAPIST

   ***   N/A     ***   N/A     ***   N/A  

OCCUPATIONAL THERAPIST ASSISTANT

   ***   N/A     ***   N/A     ***   N/A  

PHLEBOTOMIST

   ***   N/A     ***   N/A     ***   N/A  

PHOTOTHERAPY PACKAGE SERVICE

   ***   N/A     ***   N/A     ***   N/A  

PHYSICAL THERAPIST

   ***   N/A     ***   N/A     ***   N/A  

PHYSICAL THERAPIST ASSISTANT

   ***   N/A     ***   N/A     ***   N/A  

PSYCHIATRIC NURSE

   ***   N/A     ***   N/A     ***   N/A  

REHABILITATION NURSE

   ***   N/A     ***   N/A     ***   N/A  

RESPIRATORY THERAPIST

   ***   N/A     ***   N/A     ***   N/A  

RN ASSESSMENT, INITIAL

   ***   N/A     ***   N/A     ***   N/A  

RN SKILLED NURSING VISIT-EXTENSIVE

   ***   N/A     ***   N/A     ***   N/A  

SPEECH THERAPIST

   ***   N/A     ***   N/A     ***   N/A  

WOUND CARE—RN

   ***   N/A     ***   N/A     ***   N/A  

WOUND CARE—LVN/LPN

   ***   N/A     ***   N/A     ***   N/A   The following Traditional Home Health
Service has Hourly only rates.  

Notes 3, 4 and 5 apply

   Area 1     Area 2     Area 3      Visit   Hour     Visit   Hour     Visit  
Hour  

HOMEMAKER

   N/A   ***     N/A   ***     N/A   ***   The following Traditional Home Health
Service is priced on a Per Diem basis.  

Notes 3, 4 and 5 apply

   Area 1     Area 2     Area 3          Per
Diem         Per
Diem         Per
Diem  

COMPANION/LIVE IN

     * **     * **     * **

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

HMO RATES EFFECTIVE FEBRUARY 1, 2008 - JANUARY 31, 2009

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP  

Ancillary Drugs

     ***   ***  

Biological Response Modifiers

     ***   ***  

Cardiac (Inotropic) Therapy

   ***     ***  

Chelation Therapy

   ***     ***  

Chemotherapy

   ***     ***  

Enzyme Therapy

   ***     ***  

Growth Hormone

     ***   ***  

IV Immune Globulin

   ***     ***  

Other Injectable Therapies

     ***   ***  

Other Infusion Therapies

   ***     ***  

Pain Management Therapy

   ***     ***  

Steroid Therapy

   ***     ***  

Thrombolytic (Anticoagulation) Therapy

   ***     ***  

Synagis

     ***   ***  

Remodulin Therapy

   ***     ***   The following Home Infusion Therapy service rates EXCLUDE
drugs. Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies        
Per Diem       Drug Discount Off AWP  

Anti-Infectives - Primary Anti-Infective

   ***     ***  

Anti-Infectives - Multiple Anti-Infective

   ***     ***   The following Home Infusion Therapy service rate EXCLUDES
drugs. Drugs are priced per vial, and there is NO price difference between
primary and multiple anti-infective therapies         Primary or
Multiple Therapy
Per Diem       Cost of Drug  

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       * **

Flolan 1.5 mg vial

       * **

Flolan diluent vial

       * ** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies        
Primary or
Multiple Therapy
Per Diem          

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY HMO FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs - including but not limited to
cost of drugs, facility overhead, supplies, delivery, professional labor
including compounding and monitoring, all nursing required, maintenance of
specialized catheters, equipment/patient supplies, disposables, pumps, general
and administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

         ***

Catheter Care Per Diem

         ***

Midline Insertion (Catheter & Supplies)

         ***

PICC Line Insertion (Catheter & Supplies)

         ***

Blood Product

         ***

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO FEE-FOR-SERVICE RATES

 

Factor Concentrates

 

                  Vial price   Unit Price Factor VII        

Novoseven 1200MCG Vial

      ***  

Novoseven 4800MCG Vial

      ***  

Novoseven in 1200MCG or 4800MCG QTY

        *** Factor VIII (Recombinant)        

Recombinate

        ***

Kogenate or Helixate

        ***

Bioclate

        ***

Helixate FS

        ***

Kogenate FS

        ***

Refacto

        ***

Advate

        *** Factor VIII (Monoclonal)        

Hemofil-M or A. R. C. Method M

        ***

Monoclate P

        ***

Monarc-M

        *** Factor VIII (Other)        

Koate

        ***

Humate

        ***

Alphanate SDHT

        ***

Factor IX (Recombinant)

       

BeneFix

        *** Factor IX (Monoclonal/High Purity)        

Mononine

        ***

Alphanine

        *** Factor IX (Other)        

Konyne—80

        ***

Proplex T

        ***

Bebulin

        ***

Profilnine SD

        *** Anti-Inhibitor Complex        

Autoplex-T

        ***

Feiba-VH

        ***

Hyate-C

        *** HEMOSTATIC AGENTS        

DDAVP—10ml vial

        ***

Stimate —2.5ml vial

        ***

Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

HMO RATES EFFECTIVE FEBRUARY 1, 2009—JANUARY 31, 2010

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP  

Ancillary Drugs

     ***   ***  

Biological Response Modifiers

     ***   ***  

Cardiac (Inotropic) Therapy

   ***     ***  

Chelation Therapy

   ***     ***  

Chemotherapy

   ***     ***  

Enzyme Therapy

   ***     ***  

Growth Hormone

     ***   ***  

IV Immune Globulin

   ***     ***  

Other Injectable Therapies

     ***   ***  

Other Infusion Therapies

   ***     ***  

Pain Management Therapy

   ***     ***  

Steroid Therapy

   ***     ***  

Thrombolytic (Anticoagulation) Therapy

   ***     ***  

Synagis

     ***   ***  

Remodulin Therapy

   ***     ***   The following Home Infusion Therapy service rates EXCLUDE
drugs. Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies         Per
Diem       Drug Discount Off
AWP  

Anti-Infectives—Primary Anti-Infective

   ***     ***  

Anti-Infectives—Multiple Anti-Infective

   ***     ***   The following Home Infusion Therapy service rate EXCLUDES
drugs. Drugs are priced per vial, and there is NO price difference between
primary and multiple anti-infective therapies         Primary or
Multiple Therapy
Per Diem       Cost of Drug  

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       * **

Flolan 1.5 mg vial

       * **

Flolan diluent vial

       * ** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies        
Primary or
Multiple Therapy
Per Diem          

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY HMO FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs—including but not limited to cost
of drugs, facility overhead, supplies, delivery, professional labor including
compounding and monitoring, all nursing required, maintenance of specialized
catheters, equipment/patient supplies, disposables, pumps, general and
administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

         ***

Catheter Care Per Diem

         ***

Midline Insertion (Catheter & Supplies)

         ***

PICC Line Insertion (Catheter & Supplies)

         ***

Blood Product

         ***

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO FEE-FOR-SERVICE RATES

Factor Concentrates

 

          Vial price   Unit Price Factor VII        

Novoseven 1200MCG Vial

      ***  

Novoseven 4800MCG Vial

      ***  

Novoseven in 1200MCG or 4800MCG QTY

        ***

Factor VIII (Recombinant)

       

Recombinate

        ***

Kogenate or Helixate

        ***

Bioclate

        ***

Helixate FS

        ***

Kogenate FS

        ***

Refacto

        ***

Advate

        *** Factor VIII (Monoclonal)        

Hemofil-M or A. R. C. Method M

        ***

Monoclate P

        ***

Monarc-M

        *** Factor VIII (Other)        

Koate

        ***

Humate

        ***

Alphanate SDHT

        *** Factor IX (Recombinant)        

BeneFix

        *** Factor IX (Monoclonal/High Purity)        

Mononine

        ***

Alphanine

        *** Factor IX (Other)        

Konyne—80

        ***

Proplex T

        ***

Bebulin

        ***

Profilnine SD

        *** Anti-Inhibitor Complex        

Autoplex-T

        ***

Feiba-VH

        ***

Hyate-C

        *** HEMOSTATIC AGENTS        

DDAVP—10ml vial

        ***

Stimate —2.5ml vial

        ***

Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

HMO RATES EFFECTIVE FEBRUARY 1, 2010—JANUARY 31, 2011

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP

Ancillary Drugs

     ***   ***

Biological Response Modifiers

     ***   ***

Cardiac (Inotropic) Therapy

   ***     ***

Chelation Therapy

   ***     ***

Chemotherapy

   ***     ***

Enzyme Therapy

   ***     ***

Growth Hormone

     ***   ***

IV Immune Globulin

   ***     ***

Other Injectable Therapies

     ***   ***

Other Infusion Therapies

   ***     ***

Pain Management Therapy

   ***     ***

Steroid Therapy

   ***     ***

Thrombolytic (Anticoagulation) Therapy

   ***     ***

Synagis

     ***   ***

Remodulin Therapy

   ***     *** The following Home Infusion Therapy service rates EXCLUDE drugs.
Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies      Per Diem  
    Drug Discount Off AWP

Anti-Infectives—Primary Anti-Infective

   ***     ***

Anti-Infectives—Multiple Anti-Infective

   ***     *** The following Home Infusion Therapy service rate EXCLUDES drugs.
Drugs are priced per vial, and there is NO price difference between primary and
multiple anti-infective therapies      Primary or
Multiple Therapy
Per Diem       Cost of Drug

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       ***

Flolan 1.5 mg vial

       ***

Flolan diluent vial

       *** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies      Primary
or
Multiple Therapy
Per Diem        

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY HMO FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs - including but not limited to
cost of drugs, facility overhead, supplies, delivery, professional labor
including compounding and monitoring, all nursing required, maintenance of
specialized catheters, equipment/patient supplies, disposables, pumps, general
and administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

       * **

Catheter Care Per Diem

       * **

Midline Insertion (Catheter & Supplies)

       * **

PICC Line Insertion (Catheter & Supplies)

       * **

Blood Product

       * **

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO FEE-FOR-SERVICE RATES

 

Factor Concentrates

          

Vial price

  

Unit Price

Factor VII

     

Novoseven 1200MCG Vial

   ***   

Novoseven 4800MCG Vial

   ***   

Novoseven in 1200MCG or 4800MCG QTY

      ***

Factor VIII (Recombinant)

     

Recombinate

      ***

Kogenate or Helixate

      ***

Bioclate

      ***

Helixate FS

      ***

Kogenate FS

      ***

Refacto

      ***

Advate

      ***

Factor VIII (Monoclonal)

     

Hemofil-M or A. R. C. Method M

      ***

Monoclate P

      ***

Monarc-M

      ***

Factor VIII (Other)

     

Koate

      ***

Humate

      ***

Alphanate SDHT

      ***

Factor IX (Recombinant)

     

BeneFix

      ***

Factor IX (Monoclonal/High Purity)

     

Mononine

      ***

Alphanine

      ***

Factor IX (Other)

     

Konyne - 80

      ***

Proplex T

      ***

Bebulin

      ***

Profilnine SD

      ***

Anti-Inhibitor Complex

     

Autoplex-T

      ***

Feiba-VH

      ***

Hyate-C

      ***

HEMOSTATIC AGENTS

     

DDAVP - 10ml vial

      ***

Stimate - 2.5ml vial

      ***

Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

DME / HME RESPIRATORY RATES:

HMO RATES EFFECTIVE FEBRUARY 1, 2008—JANUARY 31. 2011

 

CAT

  

TYPE

   HCPCS
CODE    CHC
CODE    CareCentrix
Code   

DESCRIPTION

  

PURCHASE
PRICE

  

RENTAL
PRICE

  

DAILY
PRICE

HME

      A4230    A4230       Infusion set for external insulin pump, non-needle
cannula Type    ***      

HME

      A4231    A4231       Infusion set for external insulin pump, needle type
   ***      

HME

      A4232    A4232       Reservoir/Syringe with needle for external insulin
pump    ***      

HME

      A4632    A4632       Replacement battery for external insulin pump, any
type, each    ***      

HME

      A5119    A5119       Skin Barrier, wipes, box per 50    ***      

HME

      A6257    A6257       Transparent film/dressing    ***      

HME

   INSULPP    E0784    E0784    2158    PUMP (E0784), EXT AMBULATORY INFUSION,
MINIMED, INSULIN    ***      

HME

   INSULPP    E0784    E0784    8563    PUMP DISETRONIC ACCU-CHEK SPIRIT,
INSULIN (E0784)    ***      

HME

   INSULPP    E0784    E0784    7704    PUMP, EXT INFUSION, DANA DIABECARE,
INSULIN (E0784)    ***      

HME

   INSULPP    E0784    E0784    7731    PUMP, EXT INFUSION, ANIMAS, INSULIN
(E0784)    ***      

HME

   INSULPP    E0784    E0784    7773    PUMP (E0784), EXT AMBULATORY INFUSION,
DELTEC, INSULIN    ***      

HME

   OTHER    E0746    DM570    2109    ELECTROMYOGRAPHY (EMG) (E0746),
BIOFEEDBACK DEVICE    ***    ***   

HME

   OTHER    E0935    E0935    2125    PASSIVE MOTION (E0935) EXERCISE DEVICE   
      ***

HME

   OTHER    E0935    E0935    2857    PASSIVE MOTION (E0935) EXERCISE DEVICE,
HAND          ***

HME

   OTHER    E0935    E0935    2858    PASSIVE MOTION (E0935) EXERCISE DEVICE,
SHOULDER          ***

HME

   OTHER    E0935    E0935    2859    PASSIVE MOTION (E0935) EXERCISE DEVICE,
ANKLE          ***

HME

   OTHER    E0935    E0935    2860    PASSIVE MOTION (E0935) EXERCISE DEVICE,
ELBOW          ***

HME

   OTHER    E0935    E0935    2861    PASSIVE MOTION (E0935) EXERCISE DEVICE,
WRIST          ***

HME

   OTHER    E1300    DM570    2062    WHIRLPOOL (E1300), PORT (OVERTUB TYPE)   
***      

HME

   OTHER    E1310    DM570    2061    WHIRLPOOL (E1399), NON-PORT (BUILT-IN
TYPE)    ***      

HME

   OTHER    E1399    E1399    2327    DURABLE MEDICAL EQUIP (E1399),
MISCELLANEOUS    ***      

HME

   WDSUCT    K0538    DM570    6873    WOUND SUCTION DEVICE (K0538)          ***

HME

   WDSUCT    K0539    DM570    7914    DRESSING SET, FOR WOUND SUCTION DEVICE
(K0539)    ***      

HME

   WDSUCT    K0540    DM570    7915    CANISTER SET, FOR WOUND SUCTION DEVICE
(K0540)    ***      

The following may be charged under extraordinary circumstances:

HME

   SUP    E1399    E1399    4551    LABOR/SERVICE/SHIPPING CHARGES    ***      

HME

   SUP    E1399    E1399    2731    SHIPPING AND HANDLING FEES    ***      

The following may be charged if over and above routine on rental equipment:

RESP

   EQUIP    E1350    E1350    2382    REPAIR OR NON-ROUTINE (E1350) SERVICE
REQUIRING SKILL OF A TECH    ***      

HME

   SUP    E1399    E1399    4552    MISCELLANEOUS SUPPLIES    ***       ***

NOTES:

 

1. Whether rental or purchase, rates include all shipping, labor and set-up.

 

2. If item is rented, rates include all supplies to enable the equipment to
function effectively with the exception Suction and CPM. Such exception supplies
will be billed at ***.

 

3. If item is rented, rates include repair and maintenance costs.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

EXHIBIT A

GATEKEEPER PROGRAM ATTACHMENT - CAPITATION

SCHEDULE OF CAPITATION RATES

CAPITATION RATES EFFECTIVE 2/1/08 - 1/31/09

These are the capitation rates that apply to services rendered to Patient Panel
Participants enrolled in Gatekeeper Programs. A “Gatekeeper Program” means (i) a
product that includes fully insured Standard HMO, Point of Service, or
Gatekeeper PPO benefits and which is underwritten by a licensed insurance
company based on an experience rating methodology, or (ii) a self funded product
which includes Standard HMO, Point of Service, or Gatekeeper PPO benefits. This
definition includes, but is not limited to, Participants covered under FlexCare
plans insured/administered by Connecticut General Life Insurance Company.

 

     CareCentrix
Home Health,
Infusion, DME/
HME
Capitation Rates
PMPM

All Gatekeeper (FlexCare) Capitated Affiliates

   ***

Capitation Rate Compensation Terms

The following rates are established for the provision of Home Care Services
rendered to Program Participants covered under the HMO and Gatekeeper plans:

 

February 1, 2008 - January 31, 2009    *** per member per month February 1, 2009
- January 31, 2010    *** per member per month February 1, 2010 - January 31,
2011    *** per member per month

The capitation rate listed avove will be allocated between HMO and Gatekeeper
Program particiants in accordance with established business practices. On or
about February 1 of each year, the parties shall reconcile the allocation and
settle any payment difference no later than February 28 of each calendar year.

If an outlier calcuation for *** demonstrates a patient per thousand (PPK)
increase in excess of ***, (***), then MCA reserves the right to propose an ***
pmpm outlier adjustment. CIGNA may elect to accept this adjustment or *** and
*** from this agreement.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

EXHIBIT A

GATEKEEPER PROGRAM ATTACHMENT - FEE FOR SERVICE

REIMBURSEMENT FOR OTHER SERVICES

RATE AREA DESIGNATIONS:

 

STATE

 

RATE AREA

 

RATE DESIGNATION

Alabama

  ***   ***

Alaska

  ***   ***

Arizona

  ***   ***

Arkansas

  ***   ***

California

  ***   ***

Colorado

  ***   ***

Connecticut

  ***   ***

Delaware

  ***   ***

District of Columbia

  ***   ***

Florida

  ***   ***

Georgia

  ***   ***

Hawaii

  ***   ***

Idaho

  ***   ***

Illinois

  ***   ***

Indiana

  ***   ***

Iowa

  ***   ***

Kansas

  ***   ***

Kentucky

  ***   ***

Louisiana

  ***   ***

Maine

  ***   ***

Maryland

  ***   ***

Massachusetts

  ***   ***

Michigan

  ***   ***

Minnesota

  ***   ***

Mississippi

  ***   ***

Missouri

  ***   ***

Montana

  ***   ***

Nebraska

  ***   ***

Nevada

  ***   ***

New Hampshire

  ***   ***

New Jersey

  ***   ***

New Mexico

  ***   ***

New York

  ***   ***

North Carolina

  ***   ***

North Dakota

  ***   ***

Ohio

  ***   ***

Oklahoma

  ***   ***

Oregon

  ***   ***

Pennsylvania

  ***   ***

Rhode Island

  ***   ***

South Carolina

  ***   ***

South Dakota

  ***   ***

Tennessee

  ***   ***

Texas

  ***   ***

Utah

  ***   ***

Vermont

  ***   ***

Virginia

  ***   ***

Washington

  ***   ***

West Virginia

  ***   ***

Wisconsin

  ***   ***

Wyoming

  ***   ***

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

GATEKEEPER RATES EFFECTIVE FEBRUARY 1, 2008 - JANUARY 31, 2009

The following Traditional Home Health Services have both Visit and Hourly rates.

 

Notes 1, 2, 3, 4, 5 and 6 apply

  

Area 1

  

Area 2

  

Area 3

  

Visit

  

Hour

  

Visit

  

Hour

  

Visit

  

Hour

CERTIFIED NURSES AIDE

   ***    ***    ***    ***    ***    ***

HOME HEALTH AIDE

   ***    ***    ***    ***    ***    ***

LVN/LPN

   ***    ***    ***    ***    ***    ***

LVN/LPN—HIGH TECH

   ***    ***    ***    ***    ***    ***

PEDIATRIC HIGH TECH LVN/LPN

   ***    ***    ***    ***    ***    ***

PEDIATRIC HIGH TECH RN

   ***    ***    ***    ***    ***    ***

PEDIATRIC LVN/LPN

   ***    ***    ***    ***    ***    ***

PEDIATRIC RN

   ***    ***    ***    ***    ***    ***

RN

   ***    ***    ***    ***    ***    ***

RN HIGH TECH INFUSION

   ***    ***    ***    ***    ***    ***

RN HIGH TECH OTHER

   ***    ***    ***    ***    ***    *** The following Traditional Home Health
Services have Visit only rates.                  

Notes 1, 3, 4, 5, 7 and 8 apply

  

Area 1

  

Area 2

  

Area 3

  

Visit

  

Hour

  

Visit

  

Hour

  

Visit

  

Hour

DIABETIC NURSE

   ***    N/A    ***    N/A    ***    N/A

DIETITIAN

   ***    N/A    ***    N/A    ***    N/A

ENTEROSTOMAL THERAPIST

   ***    N/A    ***    N/A    ***    N/A

MATERNAL CHILD HEALTH

   ***    N/A    ***    N/A    ***    N/A

MEDICAL SOCIAL WORKER

   ***    N/A    ***    N/A    ***    N/A

OCCUPATIONAL THERAPIST

   ***    N/A    ***    N/A    ***    N/A

OCCUPATIONAL THERAPIST ASSISTANT

   ***    N/A    ***    N/A    ***    N/A

PHLEBOTOMIST

   ***    N/A    ***    N/A    ***    N/A

PHOTOTHERAPY PACKAGE SERVICE

   ***    N/A    ***    N/A    ***    N/A

PHYSICAL THERAPIST

   ***    N/A    ***    N/A    ***    N/A

PHYSICAL THERAPIST ASSISTANT

   ***    N/A    ***    N/A    ***    N/A

PSYCHIATRIC NURSE

   ***    N/A    ***    N/A    ***    N/A

REHABILITATION NURSE

   ***    N/A    ***    N/A    ***    N/A

RESPIRATORY THERAPIST

   ***    N/A    ***    N/A    ***    N/A

RN ASSESSMENT, INITIAL

   ***    N/A    ***    N/A    ***    N/A

RN SKILLED NURSING VISIT-EXTENSIVE

   ***    N/A    ***    N/A    ***    N/A

SPEECH THERAPIST

   ***    N/A    ***    N/A    ***    N/A

WOUND CARE—RN

   ***    N/A    ***    N/A    ***    N/A

WOUND CARE—LVN/LPN

   ***    N/A    ***    N/A    ***    N/A The following Traditional Home Health
Service has Hourly only rates.

Notes 3, 4 and 5 apply

  

Area 1

  

Area 2

  

Area 3

  

Visit

  

Hour

  

Visit

  

Hour

  

Visit

  

Hour

HOMEMAKER

   N/A    ***    N/A    ***    N/A    *** The following Traditional Home Health
Service is priced on a Per Diem basis.

Notes 3, 4 and 5 apply

  

Area 1

  

Area 2

  

Area 3

       

Per

Diem

       

Per

Diem

       

Per
Diem

COMPANION/LIVE IN       ***       ***       ***

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

GATEKEEPER RATES EFFECTIVE FEBRUARY 1, 2009 - JANUARY 31, 2010

The following Traditional Home Health Services have both Visit and Hourly rates.

 

     

Area 1

  

Area 2

  

Area 3

Notes 1, 2, 3, 4, 5 and 6 apply

  

Visit

  

Hour

  

Visit

  

Hour

  

Visit

  

Hour

CERTIFIED NURSES AIDE

   ***    ***    ***    ***    ***    ***

HOME HEALTH AIDE

   ***    ***    ***    ***    ***    ***

LVN/LPN

   ***    ***    ***    ***    ***    ***

LVN/LPN—HIGH TECH

   ***    ***    ***    ***    ***    ***

PEDIATRIC HIGH TECH LVN/LPN

   ***    ***    ***    ***    ***    ***

PEDIATRIC HIGH TECH RN

   ***    ***    ***    ***    ***    ***

PEDIATRIC LVN/LPN

   ***    ***    ***    ***    ***    ***

PEDIATRIC RN

   ***    ***    ***    ***    ***    ***

RN

   ***    ***    ***    ***    ***    ***

RN HIGH TECH INFUSION

   ***    ***    ***    ***    ***    ***

RN HIGH TECH OTHER

   ***    ***    ***    ***    ***    *** The following Traditional Home Health
Services have Visit only rates.      

Area 1

  

Area 2

  

Area 3

Notes 1, 3, 4, 5, 7 and 8 apply

  

Visit

  

Hour

  

Visit

  

Hour

  

Visit

  

Hour

DIABETIC NURSE

   ***    N/A    ***    N/A    ***    N/A

DIETITIAN

   ***    N/A    ***    N/A    ***    N/A

ENTEROSTOMAL THERAPIST

   ***    N/A    ***    N/A    ***    N/A

MATERNAL CHILD HEALTH

   ***    N/A    ***    N/A    ***    N/A

MEDICAL SOCIAL WORKER

   ***    N/A    ***    N/A    ***    N/A

OCCUPATIONAL THERAPIST

   ***    N/A    ***    N/A    ***    N/A

OCCUPATIONAL THERAPIST ASSISTANT

   ***    N/A    ***    N/A    ***    N/A

PHLEBOTOMIST

   ***    N/A    ***    N/A    ***    N/A

PHOTOTHERAPY PACKAGE SERVICE

   ***    N/A    ***    N/A    ***    N/A

PHYSICAL THERAPIST

   ***    N/A    ***    N/A    ***    N/A

PHYSICAL THERAPIST ASSISTANT

   ***    N/A    ***    N/A    ***    N/A

PSYCHIATRIC NURSE

   ***    N/A    ***    N/A    ***    N/A

REHABILITATION NURSE

   ***    N/A    ***    N/A    ***    N/A

RESPIRATORY THERAPIST

   ***    N/A    ***    N/A    ***    N/A

RN ASSESSMENT, INITIAL

   ***    N/A    ***    N/A    ***    N/A

RN SKILLED NURSING VISIT-EXTENSIVE

   ***    N/A    ***    N/A    ***    N/A

SPEECH THERAPIST

   ***    N/A    ***    N/A    ***    N/A

WOUND CARE—RN

   ***    N/A    ***    N/A    ***    N/A

WOUND CARE—LVN/LPN

   ***    N/A    ***    N/A    ***    N/A The following Traditional Home Health
Service has Hourly only rates.      

Area 1

  

Area 2

  

Area 3

Notes 3, 4 and 5 apply

  

Visit

  

Hour

  

Visit

  

Hour

  

Visit

  

Hour

HOMEMAKER

   N/A    ***    N/A    ***    N/A    *** The following Traditional Home Health
Service is priced on a Per Diem basis.      

Area 1

  

Area 2

  

Area 3

Notes 3, 4 and 5 apply

       

Per

Diem

       

Per

Diem

       

Per
Diem

COMPANION/LIVE IN       ***       ***       ***

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

GATEKEEPER RATES EFFECTIVE FEBRUARY 1, 2010—JANUARY 31, 2011

The following Traditional Home Health Services have both Visit and Hourly rates.

 

Notes 1, 2, 3, 4, 5 and 6 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

CERTIFIED NURSES AIDE

   ***   ***   ***   ***   ***   ***

HOME HEALTH AIDE

   ***   ***   ***   ***   ***   ***

LVN/LPN

   ***   ***   ***   ***   ***   ***

LVN/LPN—HIGH TECH

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH RN

   ***   ***   ***   ***   ***   ***

PEDIATRIC LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC RN

   ***   ***   ***   ***   ***   ***

RN

   ***   ***   ***   ***   ***   ***

RN HIGH TECH INFUSION

   ***   ***   ***   ***   ***   ***

RN HIGH TECH OTHER

   ***   ***   ***   ***   ***   *** The following Traditional Home Health
Services have Visit only rates.

Notes 1, 3, 4, 5, 7 and 8 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

DIABETIC NURSE

   ***   N/A   ***   N/A   ***   N/A

DIETITIAN

   ***   N/A   ***   N/A   ***   N/A

ENTEROSTOMAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

MATERNAL CHILD HEALTH

   ***   N/A   ***   N/A   ***   N/A

MEDICAL SOCIAL WORKER

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PHLEBOTOMIST

   ***   N/A   ***   N/A   ***   N/A

PHOTOTHERAPY PACKAGE SERVICE

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PSYCHIATRIC NURSE

   ***   N/A   ***   N/A   ***   N/A

REHABILITATION NURSE

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST

   ***   N/A   ***   N/A   ***   N/A

RN ASSESSMENT, INITIAL

   ***   N/A   ***   N/A   ***   N/A

RN SKILLED NURSING VISIT-EXTENSIVE

   ***   N/A   ***   N/A   ***   N/A

SPEECH THERAPIST

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—RN

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—LVN/LPN

   ***   N/A   ***   N/A   ***   N/A The following Traditional Home Health
Service has Hourly only rates.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

HOMEMAKER

   N/A   ***   N/A   ***   N/A   *** The following Traditional Home Health
Service is priced on a Per Diem basis.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3        Per
Diem       Per
Diem       Per
Diem

COMPANION/LIVE IN

     ***     ***     ***

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

GATEKEEPER RATES EFFECTIVE FEBRUARY 1, 2008—JANUARY 31, 2009

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP

Ancillary Drugs

     ***   ***

Biological Response Modifiers

     ***   ***

Cardiac (Inotropic) Therapy

   ***     ***

Chelation Therapy

   ***     ***

Chemotherapy

   ***     ***

Enzyme Therapy

   ***     ***

Growth Hormone

     ***   ***

IV Immune Globulin

   ***     ***

Other Injectable Therapies

     ***   ***

Other Infusion Therapies

   ***     ***

Pain Management Therapy

   ***     ***

Steroid Therapy

   ***     ***

Thrombolytic (Anticoagulation) Therapy

   ***     ***

Synagis

     ***   ***

Remodulin Therapy

   ***     *** The following Home Infusion Therapy service rates EXCLUDE drugs.
Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies      Per Diem  
    Drug Discount Off AWP

Anti-Infectives—Primary Anti-Infective

   ***     ***

Anti-Infectives—Multiple Anti-Infective

   ***     *** The following Home Infusion Therapy service rate EXCLUDES drugs.
Drugs are priced per vial, and there is NO price difference between primary and
multiple anti-infective therapies      Primary or
Multiple Therapy
Per Diem       Cost of Drug

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       ***

Flolan 1.5 mg vial

       ***

Flolan diluent vial

       *** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies      Primary
or
Multiple Therapy
Per Diem        

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY GATEKEEPER FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs—including but not limited to cost
of drugs, facility overhead, supplies, delivery, professional labor including
compounding and monitoring, all nursing required, maintenance of specialized
catheters, equipment/patient supplies, disposables, pumps, general and
administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

       * **

Catheter Care Per Diem

       * **

Midline Insertion (Catheter & Supplies)

       * **

PICC Line Insertion (Catheter & Supplies)

       * **

Blood Product

       * **

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY GATEKEEPER FEE-FOR-SERVICE RATES

Factor Concentrates

 

     Vial price   Unit Price Factor VII     

Novoseven 1200MCG Vial

   ***  

Novoseven 4800MCG Vial

   ***  

Novoseven in 1200MCG or 4800MCG QTY

     *** Factor VIII (Recombinant)     

Recombinate

     ***

Kogenate or Helixate

     ***

Bioclate

     ***

Helixate FS

     ***

Kogenate FS

     ***

Refacto

     ***

Advate

     *** Factor VIII (Monoclonal)     

Hemofil-M or A. R. C. Method M

     ***

Monoclate P

     ***

Monarc-M

     *** Factor VIII (Other)     

Koate

     ***

Humate

     ***

Alphanate SDHT

     *** Factor IX (Recombinant)     

BeneFix

     *** Factor IX (Monoclonal/High Purity)     

Mononine

     ***

Alphanine

     *** Factor IX (Other)     

Konyne—80

     ***

Proplex T

     ***

Bebulin

     ***

Profilnine SD

     *** Anti-Inhibitor Complex     

Autoplex-T

     ***

Feiba-VH

     ***

Hyate-C

     *** HEMOSTATIC AGENTS     

DDAVP—10ml vial

     ***

Stimate —2.5ml vial

     ***

Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

GATEKEEPER RATES EFFECTIVE FEBRUARY 1, 2009—JANUARY 31, 2010

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP

Ancillary Drugs

     ***   ***

Biological Response Modifiers

     ***   ***

Cardiac (Inotropic) Therapy

   ***     ***

Chelation Therapy

   ***     ***

Chemotherapy

   ***     ***

Enzyme Therapy

   ***     ***

Growth Hormone

     ***   ***

IV Immune Globulin

   ***     ***

Other Injectable Therapies

     ***   ***

Other Infusion Therapies

   ***     ***

Pain Management Therapy

   ***     ***

Steroid Therapy

   ***     ***

Thrombolytic (Anticoagulation) Therapy

   ***     ***

Synagis

     ***   ***

Remodulin Therapy

   ***     *** The following Home Infusion Therapy service rates EXCLUDE drugs.
Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies      Per Diem  
    Drug Discount Off AWP

Anti-Infectives—Primary Anti-Infective

   ***     ***

Anti-Infectives—Multiple Anti-Infective

   ***     *** The following Home Infusion Therapy service rate EXCLUDES drugs.
Drugs are priced per vial, and there is NO price difference between primary and
multiple anti-infective therapies      Primary or
Multiple Therapy
Per Diem       Cost of Drug

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       ***

Flolan 1.5 mg vial

       ***

Flolan diluent vial

       *** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies      Primary
or
Multiple Therapy
Per Diem        

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY GATEKEEPER FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs—including but not limited to cost
of drugs, facility overhead, supplies, delivery, professional labor including
compounding and monitoring, all nursing required, maintenance of specialized
catheters, equipment/patient supplies, disposables, pumps, general and
administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

         ***

Catheter Care Per Diem

         ***

Midline Insertion (Catheter & Supplies)

         ***

PICC Line Insertion (Catheter & Supplies)

         ***

Blood Product

         ***

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY GATEKEEPER FEE-FOR-SERVICE RATES

Factor Concentrates

 

     Vial price   Unit Price

Factor VII

    

Novoseven 1200MCG Vial

   ***  

Novoseven 4800MCG Vial

   ***  

Novoseven in 1200MCG or 4800MCG QTY

     ***

Factor VIII (Recombinant)

    

Recombinate

     ***

Kogenate or Helixate

     ***

Bioclate

     ***

Helixate FS

     ***

Kogenate FS

     ***

Refacto

     ***

Advate

     ***

Factor VIII (Monoclonal)

    

Hemofil-M or A. R. C. Method M

     ***

Monoclate P

     ***

Monarc-M

     ***

Factor VIII (Other)

    

Koate

     ***

Humate

     ***

Alphanate SDHT

     ***

Factor IX (Recombinant)

    

BeneFix

     ***

Factor IX (Monoclonal/High Purity)

    

Mononine

     ***

Alphanine

     ***

Factor IX (Other)

    

Konyne—80

     ***

Proplex T

     ***

Bebulin

     ***

Profilnine SD

     ***

Anti-Inhibitor Complex

    

Autoplex-T

     ***

Feiba-VH

     ***

Hyate-C

     ***

HEMOSTATIC AGENTS

    

DDAVP—10ml vial

     ***

Stimate —2.5ml vial

     ***

Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

GATEKEEPER RATES EFFECTIVE FEBRUARY 1, 2010—JANUARY 31, 2011

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP

Ancillary Drugs

     ***   ***

Biological Response Modifiers

     ***   ***

Cardiac (Inotropic) Therapy

   ***     ***

Chelation Therapy

   ***     ***

Chemotherapy

   ***     ***

Enzyme Therapy

   ***     ***

Growth Hormone

     ***   ***

IV Immune Globulin

   ***     ***

Other Injectable Therapies

     ***   ***

Other Infusion Therapies

   ***     ***

Pain Management Therapy

   ***     ***

Steroid Therapy

   ***     ***

Thrombolytic (Anticoagulation) Therapy

   ***     ***

Synagis

     ***   ***

Remodulin Therapy

   ***     *** The following Home Infusion Therapy service rates EXCLUDE drugs.
Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies      Per Diem  
    Drug Discount Off
AWP

Anti-Infectives—Primary Anti-Infective

   ***     ***

Anti-Infectives—Multiple Anti-Infective

   ***     *** The following Home Infusion Therapy service rate EXCLUDES drugs.
Drugs are priced per vial, and there is NO price difference between primary and
multiple anti-infective therapies      Primary or
Multiple Therapy
Per Diem       Cost of Drug

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       ***

Flolan 1.5 mg vial

       ***

Flolan diluent vial

       *** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies      Primary
or
Multiple Therapy
Per Diem        

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY GATEKEEPER FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs—including but not limited to cost
of drugs, facility overhead, supplies, delivery, professional labor including
compounding and monitoring, all nursing required, maintenance of specialized
catheters, equipment/patient supplies, disposables, pumps, general and
administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

         ***

Catheter Care Per Diem

         ***

Midline Insertion (Catheter & Supplies)

         ***

PICC Line Insertion (Catheter & Supplies)

         ***

Blood Product

         ***

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY GATEKEEPER FEE-FOR-SERVICE RATES

Factor Concentrates

 

     Vial price   Unit Price

Factor VII

    

Novoseven 1200MCG Vial

   ***  

Novoseven 4800MCG Vial

   ***  

Novoseven in 1200MCG or 4800MCG QTY

     ***

Factor VIII (Recombinant)

    

Recombinate

     ***

Kogenate or Helixate

     ***

Bioclate

     ***

Helixate FS

     ***

Kogenate FS

     ***

Refacto

     ***

Advate

     ***

Factor VIII (Monoclonal)

    

Hemofil-M or A. R. C. Method M

     ***

Monoclate P

     ***

Monarc-M

     ***

Factor VIII (Other)

    

Koate

     ***

Humate

     ***

Alphanate SDHT

     ***

Factor IX (Recombinant)

    

BeneFix

     ***

Factor IX (Monoclonal/High Purity)

    

Mononine

     ***

Alphanine

     ***

Factor IX (Other)

    

Konyne—80

     ***

Proplex T

     ***

Bebulin

     ***

Profilnine SD

     ***

Anti-Inhibitor Complex

    

Autoplex-T

     ***

Feiba-VH

     ***

Hyate-C

     ***

HEMOSTATIC AGENTS

    

DDAVP—10ml vial

     ***

Stimate —2.5ml vial

     ***

Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

DME / HME RESPIRATORY RATES:

GATEKEEPER RATES EFFECTIVE FEBRUARY 1, 2008—JANUARY 31. 2011

 

CAT

   TYPE    HCPCS
CODE    CHC
CODE    CareCentrix
Code   

DESCRIPTION

   PURCHASE
PRICE   RENTAL
PRICE   DAILY
PRICE HME       A4230    A4230       Infusion set for external insulin pump,
non-needle cannula Type    ***     HME       A4231    A4231       Infusion set
for external insulin pump, needle type    ***     HME       A4232    A4232      
Reservoir/Syringe with needle for external insulin pump    ***     HME      
A4632    A4632       Replacement battery for external insulin pump, any type,
each    ***     HME       A5119    A5119       Skin Barrier, wipes, box per 50
   ***     HME       A6257    A6257       Transparent film/dressing    ***    
HME    INSULPP    E0784    E0784    2158    PUMP (E0784), EXT AMBULATORY
INFUSION, MINIMED, INSULIN    ***     HME    INSULPP    E0784    E0784    8563
   PUMP DISETRONIC ACCU-CHEK SPIRIT, INSULIN (E0784)    ***     HME    INSULPP
   E0784    E0784    7704    PUMP, EXT INFUSION, DANA DIABECARE, INSULIN (E0784)
   ***     HME    INSULPP    E0784    E0784    7731    PUMP, EXT INFUSION,
ANIMAS, INSULIN (E0784)    ***     HME    INSULPP    E0784    E0784    7773   
PUMP (E0784), EXT AMBULATORY INFUSION, DELTEC, INSULIN    ***     HME    OTHER
   E0746    DM570    2109    ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK DEVICE
   ***   ***   HME    OTHER    E0935    E0935    2125    PASSIVE MOTION (E0935)
EXERCISE DEVICE        *** HME    OTHER    E0935    E0935    2857    PASSIVE
MOTION (E0935) EXERCISE DEVICE, HAND        *** HME    OTHER    E0935    E0935
   2858    PASSIVE MOTION (E0935) EXERCISE DEVICE, SHOULDER        *** HME   
OTHER    E0935    E0935    2859    PASSIVE MOTION (E0935) EXERCISE DEVICE, ANKLE
       *** HME    OTHER    E0935    E0935    2860    PASSIVE MOTION (E0935)
EXERCISE DEVICE, ELBOW        *** HME    OTHER    E0935    E0935    2861   
PASSIVE MOTION (E0935) EXERCISE DEVICE, WRIST        *** HME    OTHER    E1300
   DM570    2062    WHIRLPOOL (E1300), PORT (OVERTUB TYPE)    ***     HME   
OTHER    E1310    DM570    2061    WHIRLPOOL (E1399), NON-PORT (BUILT-IN TYPE)
   ***     HME    OTHER    E1399    E1399    2327    DURABLE MEDICAL EQUIP
(E1399), MISCELLANEOUS    ***     HME    WDSUCT    K0538    DM570    6873   
WOUND SUCTION DEVICE (K0538)        *** HME    WDSUCT    K0539    DM570    7914
   DRESSING SET, FOR WOUND SUCTION DEVICE (K0539)    ***     HME    WDSUCT   
K0540    DM570    7915    CANISTER SET, FOR WOUND SUCTION DEVICE (K0540)    ***
    The following may be charged under extraordinary circumstances: HME    SUP
   E1399    E1399    4551    LABOR/SERVICE/SHIPPING CHARGES    ***     HME   
SUP    E1399    E1399    2731    SHIPPING AND HANDLING FEES    ***     The
following may be charged if over and above routine on rental equipment: RESP   
EQUIP    E1350    E1350    2382    REPAIR OR NON-ROUTINE (E1350) SERVICE
REQUIRING SKILL OF A TECH    ***     HME    SUP    E1399    E1399    4552   
MISCELLANEOUS SUPPLIES    ***     ***

NOTES:

 

1. Whether rental or purchase, rates include all shipping, labor and set-up.

 

2. If item is rented, rates include all supplies to enable the equipment to
function effectively with the exception Suction and CPM. Such exception supplies
will be billed at ***.

 

3. If item is rented, rates include repair and maintenance costs.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

EXHIBIT A

PPO & INDEMNITY PROGRAM ATTACHMENT—FEE FOR SERVICE

REIMBURSEMENT FOR OTHER SERVICES

RATE AREA DESIGNATIONS:

 

STATE

 

RATE AREA

 

RATE DESIGNATION

Alabama

  ***   ***

Alaska

  ***   ***

Arizona

  ***   ***

Arkansas

  ***   ***

California

  ***   ***

Colorado

  ***   ***

Connecticut

  ***   ***

Delaware

  ***   ***

District of Columbia

  ***   ***

Florida

  ***   ***

Georgia

  ***   ***

Hawaii

  ***   ***

Idaho

  ***   ***

Illinois

  ***   ***

Indiana

  ***   ***

Iowa

  ***   ***

Kansas

  ***   ***

Kentucky

  ***   ***

Louisiana

  ***   ***

Maine

  ***   ***

Maryland

  ***   ***

Massachusetts

  ***   ***

Michigan

  ***   ***

Minnesota

  ***   ***

Mississippi

  ***   ***

Missouri

  ***   ***

Montana

  ***   ***

Nebraska

  ***   ***

Nevada

  ***   ***

New Hampshire

  ***   ***

New Jersey

  ***   ***

New Mexico

  ***   ***

New York

  ***   ***

North Carolina

  ***   ***

North Dakota

  ***   ***

Ohio

  ***   ***

Oklahoma

  ***   ***

Oregon

  ***   ***

Pennsylvania

  ***   ***

Rhode Island

  ***   ***

South Carolina

  ***   ***

South Dakota

  ***   ***

Tennessee

  ***   ***

Texas

  ***   ***

Utah

  ***   ***

Vermont

  ***   ***

Virginia

  ***   ***

Washington

  ***   ***

West Virginia

  ***   ***

Wisconsin

  ***   ***

Wyoming

  ***   ***

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

PPO AND INDEMNITY RATES EFFECTIVE FEBRUARY 1, 2008—JANUARY 31, 2009

The following Traditional Home Health Services have both Visit and Hourly rates.

 

Notes 1, 2, 3, 4, 5 and 6 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

CERTIFIED NURSES AIDE

   ***   ***   ***   ***   ***   ***

HOME HEALTH AIDE

   ***   ***   ***   ***   ***   ***

LVN/LPN

   ***   ***   ***   ***   ***   ***

LVN/LPN—HIGH TECH

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH RN

   ***   ***   ***   ***   ***   ***

PEDIATRIC LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC RN

   ***   ***   ***   ***   ***   ***

RN

   ***   ***   ***   ***   ***   ***

RN HIGH TECH INFUSION

   ***   ***   ***   ***   ***   ***

RN HIGH TECH OTHER

   ***   ***   ***   ***   ***   *** The following Traditional Home Health
Services have Visit only rates.

Notes 1, 3, 4, 5, 7 and 8 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

DIABETIC NURSE

   ***   N/A   ***   N/A   ***   N/A

DIETITIAN

   ***   N/A   ***   N/A   ***   N/A

ENTEROSTOMAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

MATERNAL CHILD HEALTH

   ***   N/A   ***   N/A   ***   N/A

MEDICAL SOCIAL WORKER

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PHLEBOTOMIST

   ***   N/A   ***   N/A   ***   N/A

PHOTOTHERAPY PACKAGE SERVICE

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PSYCHIATRIC NURSE

   ***   N/A   ***   N/A   ***   N/A

REHABILITATION NURSE

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST—CPAP clinic

   ***   N/A   ***   N/A   ***   N/A

RN ASSESSMENT, INITIAL

   ***   N/A   ***   N/A   ***   N/A

RN SKILLED NURSING VISIT-EXTENSIVE

   ***   N/A   ***   N/A   ***   N/A

SPEECH THERAPIST

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—RN

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—LVN/LPN

   ***   N/A   ***   N/A   ***   N/A The following Traditional Home Health
Service has Hourly only rates.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

HOMEMAKER

   N/A   ***   N/A   ***   N/A   *** The following Traditional Home Health
Service is priced on a Per Diem basis.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3        Per
Diem       Per
Diem       Per
Diem

COMPANION/LIVE IN

     ***     ***     ***

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

PPO AND INDEMNITY RATES EFFECTIVE FEBRUARY 1, 2009—JANUARY 31, 2010

The following Traditional Home Health Services have both Visit and Hourly rates.

 

Notes 1, 2, 3, 4, 5 and 6 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

CERTIFIED NURSES AIDE

   ***   ***   ***   ***   ***   ***

HOME HEALTH AIDE

   ***   ***   ***   ***   ***   ***

LVN/LPN

   ***   ***   ***   ***   ***   ***

LVN/LPN—HIGH TECH

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH RN

   ***   ***   ***   ***   ***   ***

PEDIATRIC LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC RN

   ***   ***   ***   ***   ***   ***

RN

   ***   ***   ***   ***   ***   ***

RN HIGH TECH INFUSION

   ***   ***   ***   ***   ***   ***

RN HIGH TECH OTHER

   ***   ***   ***   ***   ***   *** The following Traditional Home Health
Services have Visit only rates.

Notes 1, 3, 4, 5, 7 and 8 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

DIABETIC NURSE

   ***   N/A   ***   N/A   ***   N/A

DIETITIAN

   ***   N/A   ***   N/A   ***   N/A

ENTEROSTOMAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

MATERNAL CHILD HEALTH

   ***   N/A   ***   N/A   ***   N/A

MEDICAL SOCIAL WORKER

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PHLEBOTOMIST

   ***   N/A   ***   N/A   ***   N/A

PHOTOTHERAPY PACKAGE SERVICE

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PSYCHIATRIC NURSE

   ***   N/A   ***   N/A   ***   N/A

REHABILITATION NURSE

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST—CPAP clinic

   ***   N/A   ***   N/A   ***   N/A

RN ASSESSMENT, INITIAL

   ***   N/A   ***   N/A   ***   N/A

RN SKILLED NURSING VISIT-EXTENSIVE

   ***   N/A   ***   N/A   ***   N/A

SPEECH THERAPIST

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—RN

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—LVN/LPN

   ***   N/A   ***   N/A   ***   N/A The following Traditional Home Health
Service has Hourly only rates.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

HOMEMAKER

   N/A   ***   N/A   ***   N/A   *** The following Traditional Home Health
Service is priced on a Per Diem basis.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3        Per
Diem       Per
Diem       Per
Diem

COMPANION/LIVE IN

     ***     ***     ***

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATES

PPO AND INDEMNITY RATES EFFECTIVE FEBRUARY 1, 2010—JANUARY 31. 2011

The following Traditional Home Health Services have both Visit and Hourly rates.

 

Notes 1, 2, 3, 4, 5 and 6 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

CERTIFIED NURSES AIDE

   ***   ***   ***   ***   ***   ***

HOME HEALTH AIDE

   ***   ***   ***   ***   ***   ***

LVN/LPN

   ***   ***   ***   ***   ***   ***

LVN/LPN—HIGH TECH

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC HIGH TECH RN

   ***   ***   ***   ***   ***   ***

PEDIATRIC LVN/LPN

   ***   ***   ***   ***   ***   ***

PEDIATRIC RN

   ***   ***   ***   ***   ***   ***

RN

   ***   ***   ***   ***   ***   ***

RN HIGH TECH INFUSION

   ***   ***   ***   ***   ***   ***

RN HIGH TECH OTHER

   ***   ***   ***   ***   ***   *** The following Traditional Home Health
Services have Visit only rates.

Notes 1, 3, 4, 5, 7 and 8 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

DIABETIC NURSE

   ***   N/A   ***   N/A   ***   N/A

DIETITIAN

   ***   N/A   ***   N/A   ***   N/A

ENTEROSTOMAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

MATERNAL CHILD HEALTH

   ***   N/A   ***   N/A   ***   N/A

MEDICAL SOCIAL WORKER

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

OCCUPATIONAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PHLEBOTOMIST

   ***   N/A   ***   N/A   ***   N/A

PHOTOTHERAPY PACKAGE SERVICE

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST

   ***   N/A   ***   N/A   ***   N/A

PHYSICAL THERAPIST ASSISTANT

   ***   N/A   ***   N/A   ***   N/A

PSYCHIATRIC NURSE

   ***   N/A   ***   N/A   ***   N/A

REHABILITATION NURSE

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST

   ***   N/A   ***   N/A   ***   N/A

RESPIRATORY THERAPIST—CPAP clinic

   ***   N/A   ***   N/A   ***   N/A

RN ASSESSMENT, INITIAL

   ***   N/A   ***   N/A   ***   N/A

RN SKILLED NURSING VISIT-EXTENSIVE

   ***   N/A   ***   N/A   ***   N/A

SPEECH THERAPIST

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—RN

   ***   N/A   ***   N/A   ***   N/A

WOUND CARE—LVN/LPN

   ***   N/A   ***   N/A   ***   N/A The following Traditional Home Health
Service has Hourly only rates.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3    Visit   Hour   Visit   Hour   Visit   Hour

HOMEMAKER

   N/A   ***   N/A   ***   N/A   *** The following Traditional Home Health
Service is priced on a Per Diem basis.

Notes 3, 4 and 5 apply

   Area 1   Area 2   Area 3        Per
Diem       Per
Diem       Per
Diem

COMPANION/LIVE IN

     ***     ***     ***

NOTES:

 

1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).

 

2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.

 

3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.

 

4. Above prices have no exclusions.

 

5. All services not listed above will be billed at *** until rates are mutually
established and become part of the fee schedule.

 

6. RN High Tech Infusion visit and hourly utilization/costs to be reported with
HIT.

 

7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.

 

8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment. Use
requires special coordination.

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

PPO AND INDEMNITY RATES EFFECTIVE FEBRUARY 1, 2008—JANUARY 31, 2009

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP

Ancillary Drugs

     ***   ***

Biological Response Modifiers

     ***   ***

Cardiac (Inotropic) Therapy

   ***     ***

Chelation Therapy

   ***     ***

Chemotherapy

   ***     ***

Enzyme Therapy

   ***     ***

Growth Hormone

     ***   ***

IV Immune Globulin

   ***     ***

Other Injectable Therapies

     ***   ***

Other Infusion Therapies

   ***     ***

Pain Management Therapy

   ***     ***

Steroid Therapy

   ***     ***

Thrombolytic (Anticoagulation) Therapy

   ***     ***

Synagis

     ***   ***

Remodulin Therapy

   ***     *** The following Home Infusion Therapy service rates EXCLUDE drugs.
Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies      Per Diem  
    Drug Discount Off AWP

Anti-Infectives—Primary Anti-Infective

   ***     ***

Anti-Infectives—Multiple Anti-Infective

   ***     *** The following Home Infusion Therapy service rate EXCLUDES drugs.
Drugs are priced per vial, and there is NO price difference between primary and
multiple anti-infective therapies      Primary or
Multiple Therapy
Per Diem       Cost of Drug

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       ***

Flolan 1.5 mg vial

       ***

Flolan diluent vial

       *** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies      Primary
or
Multiple Therapy
Per Diem        

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY PPO & INDEMNITY FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs—including but not limited to cost
of drugs, facility overhead, supplies, delivery, professional labor including
compounding and monitoring, all nursing required, maintenance of specialized
catheters, equipment/patient supplies, disposables, pumps, general and
administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable.

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

         * **

Catheter Care Per Diem

         * **

Midline Insertion (Catheter & Supplies)

         * **

PICC Line Insertion (Catheter & Supplies)

         * **

Blood Product

         * **

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY PPO & INDEMNITY FEE-FOR-SERVICE RATES

Factor Concentrates

 

          Vial price   Unit Price

Factor VII

       

Novoseven 1200MCG Vial

      ***  

Novoseven 4800MCG Vial

      ***  

Novoseven in 1200MCG or 4800MCG QTY

        ***

Factor VIII (Recombinant)

       

Recombinate

        ***

Kogenate or Helixate

        ***

Bioclate

        ***

Helixate FS

        ***

Kogenate FS

        ***

Refacto

        ***

Advate

        ***

Factor VIII (Monoclonal)

       

Hemofil-M or A. R. C. Method M

        ***

Monoclate P

        ***

Monarc-M

        ***

Factor VIII (Other)

       

Koate

        ***

Humate

        ***

Alphanate SDHT

        ***

Factor IX (Recombinant)

       

BeneFix

        ***

Factor IX (Monoclonal/High Purity)

       

Mononine

        ***

Alphanine

        ***

Factor IX (Other)

       

Konyne—80

        ***

Proplex T

        ***

Bebulin

        ***

Profilnine SD

        ***

Anti-Inhibitor Complex

       

Autoplex-T

        ***

Feiba-VH

        ***

Hyate-C

        ***

HEMOSTATIC AGENTS

       

DDAVP—10ml vial

        ***

Stimate —2.5ml vial

        ***

Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

PPO AND INDEMNITY RATES EFFECTIVE FEBRUARY 1, 2009—JANUARY 31. 2010

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP

Ancillary Drugs

     ***   ***

Biological Response Modifiers

     ***   ***

Cardiac (Inotropic) Therapy

   ***     ***

Chelation Therapy

   ***     ***

Chemotherapy

   ***     ***

Enzyme Therapy

   ***     ***

Growth Hormone

     ***   ***

IV Immune Globulin

   ***     ***

Other Injectable Therapies

     ***   ***

Other Infusion Therapies

   ***     ***

Pain Management Therapy

   ***     ***

Steroid Therapy

   ***     ***

Thrombolytic (Anticoagulation) Therapy

   ***     ***

Synagis

     ***   ***

Remodulin Therapy

   ***     *** The following Home Infusion Therapy service rates EXCLUDE drugs.
Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies      Per Diem  
    Drug Discount Off AWP

Anti-Infectives—Primary Anti-Infective

   ***     ***

Anti-Infectives—Multiple Anti-Infective

   ***     *** The following Home Infusion Therapy service rate EXCLUDES drugs.
Drugs are priced per vial, and there is NO price difference between primary and
multiple anti-infective therapies      Primary or
Multiple Therapy
Per Diem       Cost of Drug

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       ***

Flolan 1.5 mg vial

       ***

Flolan diluent vial

       *** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies      Primary
or
Multiple Therapy
Per Diem        

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY PPO & INDEMNITY FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs—including but not limited to cost
of drugs, facility overhead, supplies, delivery, professional labor including
compounding and monitoring, all nursing required, maintenance of specialized
catheters, equipment/patient supplies, disposables, pumps, general and
administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable.

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

         * **

Catheter Care Per Diem

         * **

Midline Insertion (Catheter & Supplies)

         * **

PICC Line Insertion (Catheter & Supplies)

         * **

Blood Product

         * **

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY PPO & INDEMNITY FEE-FOR-SERVICE RATES

 

Factor Concentrates

          Vial price   Unit Price

Factor VII

    

Novoseven 1200MCG Vial

   ***  

Novoseven 4800MCG Vial

   ***  

Novoseven in 1200MCG or 4800MCG QTY

     ***

Factor VIII (Recombinant)

    

Recombinate

     ***

Kogenate or Helixate

     ***

Bioclate

     ***

Helixate FS

     ***

Kogenate FS

     ***

Refacto

     ***

Advate

     ***

Factor VIII (Monoclonal)

    

Hemofil-M or A. R. C. Method M

     ***

Monoclate P

     ***

Monarc-M

     ***

Factor VIII (Other)

    

Koate

     ***

Humate

     ***

Alphanate SDHT

     ***

Factor IX (Recombinant)

    

BeneFix

     ***

Factor IX (Monoclonal/High Purity)

    

Mononine

     ***

Alphanine

     ***

Factor IX (Other)

    

Konyne—80

     ***

Proplex T

     ***

Bebulin

     ***

Profilnine SD

     ***

Anti-Inhibitor Complex

    

Autoplex-T

     ***

Feiba-VH

     ***

Hyate-C

     ***

HEMOSTATIC AGENTS

    

DDAVP—10ml vial

     ***

Stimate —2.5ml vial

     *** Above rates include all necessary ancillary supplies and waste disposal
unit; 24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

HOME INFUSION RATES

PPO AND INDEMNITY RATES EFFECTIVE FEBRUARY 1, 2010—JANUARY 31, 2011

The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies

 

     Primary or
Multiple Therapy
Per Diem   Primary or
Multiple Therapy
Dispensing Fee   Primary or
Multiple Therapy
Drug Discount off AWP

Ancillary Drugs

     ***   ***

Biological Response Modifiers

     ***   ***

Cardiac (Inotropic) Therapy

   ***     ***

Chelation Therapy

   ***     ***

Chemotherapy

   ***     ***

Enzyme Therapy

   ***     ***

Growth Hormone

     ***   ***

IV Immune Globulin

   ***     ***

Other Injectable Therapies

     ***   ***

Other Infusion Therapies

   ***     ***

Pain Management Therapy

   ***     ***

Steroid Therapy

   ***     ***

Thrombolytic (Anticoagulation) Therapy

   ***     ***

Synagis

     ***   ***

Remodulin Therapy

   ***     *** The following Home Infusion Therapy service rates EXCLUDE drugs.
Drugs are priced as a percentage discount off AWP, and there IS a price
difference between primary and multiple anti-infective therapies      Per Diem  
    Drug Discount Off AWP Anti-Infectives—Primary Anti-Infective    ***     ***
Anti-Infectives—Multiple Anti-Infective    ***     *** The following Home
Infusion Therapy service rate EXCLUDES drugs. Drugs are priced per vial, and
there is NO price difference between primary and multiple anti-infective
therapies      Primary or
Multiple Therapy
Per Diem       Cost of Drug

Flolan Therapy

   ***    

Flolan 0.5 mg vial

       ***

Flolan 1.5 mg vial

       ***

Flolan diluent vial

       *** The following Home Infusion Therapy service rates INCLUDE drugs, and
there is NO price difference between primary and multiple therapies      Primary
or
Multiple Therapy
Per Diem        

Hydration Therapy

   ***    

Total Parenteral Nutrition

   ***    

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 2: HOME INFUSION THERAPY PPO & INDEMNITY FEE-FOR-SERVICE RATES

NOTES:

 

1. Per Diems EXCLUDING drugs include all costs related to the therapy except the
cost of drugs, including but not limited to facility overhead, supplies,
delivery, professional labor including compounding and monitoring, all nursing
required, maintenance of specialized catheters, equipment/patient supplies,
disposables, pumps, general and administrative expenses, etc.

 

2. Per Diems INCLUDING drugs include ALL costs—including but not limited to cost
of drugs, facility overhead, supplies, delivery, professional labor including
compounding and monitoring, all nursing required, maintenance of specialized
catheters, equipment/patient supplies, disposables, pumps, general and
administrative expenses, etc.

 

3. “DISPENSING FEE” is defined as per each time the drug is dispensed by the
home infusion provider.

 

4. “PER DIEM” costs are the same for primary or multiple treatments for all drug
categories, except ANTI-INFECTIVES.

 

5. The per diem rate shall only be charged for those days the Participant
receives medication.

 

6. For home infusion pharmaceuticals not listed on fee schedule, *** will apply.

 

7. All Medications are subject to MAC pricing, where applicable.

The following are for the stated item ONLY. Unless otherwise noted, nursing,
supplies, etc. are NOT included.

 

Blood Transfusion per Unit (Tubing, Filters)

         * **

Catheter Care Per Diem

         * **

Midline Insertion (Catheter & Supplies)

         * **

PICC Line Insertion (Catheter & Supplies)

         * **

Blood Product

         * **

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY PPO & INDEMNITY FEE-FOR-SERVICE RATES

 

Factor Concentrates

                  Vial price     Unit Price  

Factor VII

       

Novoseven 1200MCG Vial

      * **  

Novoseven 4800MCG Vial

      * **  

Novoseven in 1200MCG or 4800MCG QTY

        * **

Factor VIII (Recombinant)

       

Recombinate

        * **

Kogenate or Helixate

        * **

Bioclate

        * **

Helixate FS

        * **

Kogenate FS

        * **

Refacto

        * **

Advate

        * **

Factor VIII (Monoclonal)

       

Hemofil-M or A. R. C. Method M

        * **

Monoclate P

        * **

Monarc-M

        * **

Factor VIII (Other)

       

Koate

        * **

Humate

        * **

Alphanate SDHT

        * **

Factor IX (Recombinant)

       

BeneFix

        * **

Factor IX (Monoclonal/High Purity)

       

Mononine

        * **

Alphanine

        * **

Factor IX (Other)

       

Konyne—80

        * **

Proplex T

        * **

Bebulin

        * **

Profilnine SD

        * **

Anti-Inhibitor Complex

       

Autoplex-T

        * **

Feiba-VH

        * **

Hyate-C

        * **

HEMOSTATIC AGENTS

       

DDAVP—10ml vial

        * **

Stimate —2.5ml vial

        * ** Above rates include all necessary ancillary supplies and waste
disposal unit; 24-hour on-call clinical support; home infusion monitoring
system; product delivery nationwide; patient training, education, and evaluation
  

 

*** Confidential Treatment Requested.

--------------------------------------------------------------------------------

DME / HME RESPIRATORY RATES:

PPO and INDEMNITY RATES EFFECTIVE FEBRUARY 1, 2008—JANUARY 31. 2011

 

CAT

  

TYPE

  

HCPCS
CODE

  

CHC
CODE

  

CareCentrix
Code

  

DESCRIPTION

  

PURCHASE
PRICE

  

RENTAL
PRICE

  

DAILY
PRICE

HME

      A4230    A4230       Infusion set for external insulin pump, non-needle
cannula Type    ***      

HME

      A4231    A4231       Infusion set for external insulin pump, needle type
   ***      

HME

      A4232    A4232       Reservoir/Syringe with needle for external insulin
pump    ***      

HME

      A4632    A4632       Replacement battery for external insulin pump, any
type, each    ***      

HME

      A5119    A5119       Skin Barrier, wipes, box per 50    ***      

HME

      A6257    A6257       Transparent film/dressing    ***      

HME

   INSULPP    E0784    E0784    2158    PUMP (E0784), EXT AMBULATORY INFUSION,
MINIMED, INSULIN    ***      

HME

   INSULPP    E0784    E0784    8563    PUMP DISETRONIC ACCU-CHEK SPIRIT,
INSULIN (E0784)    ***      

HME

   INSULPP    E0784    E0784    7704    PUMP, EXT INFUSION, DANA DIABECARE,
INSULIN (E0784)    ***      

HME

   INSULPP    E0784    E0784    7731    PUMP, EXT INFUSION, ANIMAS, INSULIN
(E0784)    ***      

HME

   INSULPP    E0784    E0784    7773    PUMP (E0784), EXT AMBULATORY INFUSION,
DELTEC, INSULIN    ***      

HME

   OTHER    E0746    DM570    2109    ELECTROMYOGRAPHY (EMG) (E0746),
BIOFEEDBACK DEVICE    ***    ***   

HME

   OTHER    E0935    E0935    2125    PASSIVE MOTION (E0935) EXERCISE DEVICE   
      ***

HME

   OTHER    E0935    E0935    2857    PASSIVE MOTION (E0935) EXERCISE DEVICE,
HAND          ***

HME

   OTHER    E0935    E0935    2858    PASSIVE MOTION (E0935) EXERCISE DEVICE,
SHOULDER          ***

HME

   OTHER    E0935    E0935    2859    PASSIVE MOTION (E0935) EXERCISE DEVICE,
ANKLE          ***

HME

   OTHER    E0935    E0935    2860    PASSIVE MOTION (E0935) EXERCISE DEVICE,
ELBOW          ***

HME

   OTHER    E0935    E0935    2861    PASSIVE MOTION (E0935) EXERCISE DEVICE,
WRIST          ***

HME

   OTHER    E1300    DM570    2062    WHIRLPOOL (E1300), PORT (OVERTUB TYPE)   
***      

HME

   OTHER    E1310    DM570    2061    WHIRLPOOL (E1399), NON-PORT (BUILT-IN
TYPE)    ***      

HME

   OTHER    E1399    E1399    2327    DURABLE MEDICAL EQUIP (E1399),
MISCELLANEOUS    ***      

HME

   WDSUCT    K0538    DM570    6873    WOUND SUCTION DEVICE (K0538)          ***

HME

   WDSUCT    K0539    DM570    7914    DRESSING SET, FOR WOUND SUCTION DEVICE
(K0539)    ***      

HME

   WDSUCT    K0540    DM570    7915    CANISTER SET, FOR WOUND SUCTION DEVICE
(K0540)    ***      

The following may be charged under extraordinary circumstances:

HME    SUP    E1399    E1399    4551    LABOR/SERVICE/SHIPPING CHARGES    ***   
   HME    SUP    E1399    E1399    2731    SHIPPING AND HANDLING FEES    ***   
  

The following may be charged if over and above routine on rental equipment:

RESP

   EQUIP    E1350    E1350    2382    REPAIR OR NON-ROUTINE (E1350) SERVICE
REQUIRING SKILL OF A TECH    ***      

HME

   SUP    E1399    E1399    4552    MISCELLANEOUS SUPPLIES    ***       ***

NOTES:

 

1. Whether rental or purchase, rates include all shipping, labor and set-up.

 

2. If item is rented, rates include all supplies to enable the equipment to
function effectively with the exception Suction and CPM. Such exception supplies
will be billed at ***.

 

3. If item is rented, rates include repair and maintenance costs.

 

 

*** Confidential Treatment Requested.