**A**
**MENDMENT**
**        T**
**O**
**        S**
**ERVICES**
** **
**AND**
**        L**
**ICENSE**
**        A**
**GREEMENT**

*Bi-Monthly      Processing of Paid Claims Data*

*Portal      Availability*

**;      Portal Access and Performance Guarantee**

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|  less than 99% but at least              96% |  2   | % |
|---------------------------------------------------|-----------|---|
|  less than 96% but at least              90% |  5   | % |
|  less than 90% but at least              80% |  10  | % |
|  less than 80% but at least              70% |  25  | % |
|  less than 70%                          |  100 | % |

*Term*

*Compensation.      *

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**Generally**

**On      Account of Changes in BCBSTX Covered Population**

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|  CAREADVANTAGE,                INC.           |   | BLUE                  CROSS AND                  BLUE                  SHIELD OF                  TEXAS,A                  DIVISION OF                  HEALTH                  CARE                  SERVICE                  CORPORATION |
|----------------------------------------------------|--------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
|                                               |   |                                                                                                                                                                                                                                                      |
|                                               |   |                                                                                                                                                                                                                                                      |
| BY:              /s/              Dennis J. Mouras |   | BY:              /s/              Carolyn Dawson                                                                                                                                                                                                          |
| TITLE:                CEO                          |   | TITLE:              Vice              president, UMPS                                                                                                                                                                                                |

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**RECURRING      SERVICES**

***Generally***

| ·   | Load                data into data processing                environment |
|--------------------|--------------------------------------------------------------------------|

| ·   | Conduct                technical and initial clinical review of data (review for                completeness) |
|--------------------|---------------------------------------------------------------------------------------------------------------|

| ·   | Run                data through conversion program |
|--------------------|----------------------------------------------------|

| ·   | Validate                data conversion |
|--------------------|-----------------------------------------|

| ·   | Prepare\run                data files though CRG algorithms |
|--------------------|-------------------------------------------------------------|

| ·   | Validate                CRG assignments (validity check) |
|--------------------|----------------------------------------------------------|

| ·   | Program                reports to generate analyses with updated data                elements |
|--------------------|-----------------------------------------------------------------------------------------------|

| ·   | Review                RPNavigator analyses results |
|--------------------|----------------------------------------------------|

| ·   | Move                into production environment |
|--------------------|-------------------------------------------------|

| ·   | Deliver                observations summary report (which would address significant changes                from                previous periods) |
|--------------------|--------------------------------------------------------------------------------------------------------------------------------------------------|

***PBM      Data***

***Reports***

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*(CareAdvantage      will provide its services in accordance with the Cycle Time Schedule set forth      in Attachment 1.2.2. Except as contemplated by the Claims Data Specifications      set forth in Attachment 1.2.1, the Cycle Time Schedule assumes (a) that there      has been no change in BCBSTX’s claims system(s) and business rules from those      provided by BCBSTX to CareAdvantage on or before August 18, 2003, and (b) that      there has been no change in the claims system(s) and business rules of the      four      external PBMs specified in this Attachment subsequent to CareAdvantage’s set-up      to receive data from such PBMs. In the event of any such change, that schedule      is subject to adjustment, and any additional services required by CareAdvantage      on account of such changes will be billed in accordance with Attachment      4.2.)*

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**CLAIMS      DATA SPECIFICATIONS**

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**CYCLE      TIME SCHEDULE**

| **FILE                TYPE/ PROCESS STEP**             |   | **STANDARD****CYCLE                TIME****BUSINESS                DAYS** |   | **DEPENDENCIES****&                NON STANDARD ISSUES**                                                                                                                                                                                                                                                                                      |   | **BCBSTX****CYCLE                TIME****BUSINESS                DAYS**                                                                                                                              |
|--------------------------------------------------------|--------|---------------------------------------------------------------------------|--------|---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|--------|------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|
| **LOAD                DATA EXTRACT**                   |   | 1                Day                                                      |   | Upon                receipt of files from BCBSTX in accordance with BCBSTX’s schedule to send                data to CAI, as specified in Attachment 1.2, Recurring                Services. If                all data files are not received on the same day, the process is delayed                until all data is received. > |   |     Add                3-5 Days                                                                                                                                                  |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **ASSESS                DATA EXTRACT**                 |   | 2                Days                                                     |   | <                Complete/valid data received Note                missing files/data elements; advise client, delay start until data                rec’d                If                any issues >                                                                                                                               |   |   Add                2-3 Days                                                                                                                                                              |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **MEMBERSHIP**                                         |   | 2                Days                                                     |   | Prepare                Membership Files **before**processing                Eligibility/ClaimsIf                any issues >                                                                                                                                                                                                                   |   | Add                2-3 Days                                                                                                                                                                          |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **ELIGIBILITY**                                        |   | 2                Days (simultaneous)not                counted in Total   |   | Process                Eligibility **simultaneous**                w/Claims If                any issues >                                                                                                                                                                                                                                     |   | Add                2-3 Days                                                                                                                                                                          |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **PHARMACY                CLAIMS**                     |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| -                INTERNAL                              |   | 5                Days                                                     |   | <                Prep Internal Rx Files                                                                                                                                                                                                                                                                                                        |   |                                                                                                                                                                                                 |
| -                EXTERNAL                              |   |                                                                      |   | Prep                External Rx Files >                                                                                                                                                                                                                                                                                    |   | Add                6-10 Days#                of days depends on: -# of external files-if                new PBM or update of prior external PBM -#                of crosswalks                      |
|                                                   |   |                                                                      |   | All                Rx Claims must be prepped and internal/external combined **before**                CRxG Algorithm Processing                                                                                                                                                                                                                   |   |                                                                                                                                                                                                 |
| CRxG                ALGORITHM                          |   | 10                Days (simultaneous)not                counted in Total  |   | Processing                time is affected by size of membership and # Analysis                Periods;**simultaneous**                w/Med Claims-next                                                                                                                                                                                          |   |                                                                                                                                                                                                 |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **MEDICAL                CLAIMS**                      |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| -                INTERNAL                              |   | 10-12                Days                                                 |   | <                Prep Internal Medical Files                                                                                                                                                                                                                                                                                                   |   |                                                                                                                                                                                                 |
| -                EXTERNAL                              |   |                                                                      |   | Prep                External Medical Files >                                                                                                                                                                                                                                                                                              |   | Add                5-6 Days #                of days depends on:-#                of external files-if                new or update of previous files-                #                of crosswalks |
|                                                   |   |                                                                      |   | All                Medical Claims must be prepped and internal/external combined **before**                CRG Algorithm Processing                                                                                                                                                                                                               |   |                                                                                                                                                                                                 |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **PROVIDER**                                           |   | 1                Day (simultaneous)not                counted in Total    |   | Prep/process                Files **simultaneous**w/Claims                                                                                                                                                                                                                                                                                        |   |                                                                                                                                                                                                 |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **CRG                GROUPER PROCESSING**              |   | 3-4                Days                                                   |   | All                above steps must be completed **before**                proceeding to remaining steps below                                                                                                                                                                                                                                    |   |                                                                                                                                                                                                 |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **POST                GROUPER PROCESSING**             |   | 2                Days                                                     |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **TABLE/APPL                LOADING**                  |   | 3-5                Days                                                   |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **CAI                UAT and Application Refinements** |   | 3                Days                                                     |   | UAT/Application                refinements can take longer; when RPNavigator calculations are                implausible, due to shortcomings in standard BCBSTX data extract,                rework/delays occur >                                                                                                                            |   | #                days delay depends on significance of data issues discovered; some                issues                cannot be identified until data is in RPNavigator                           |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **BCBSTX                UAT**                          |   | 3                Days                                                     |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **PRODUCTION                LOAD/TEST**                |   | 1                Day                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
|                                                   |   |                                                                      |   |                                                                                                                                                                                                                                                                                                                                              |   |                                                                                                                                                                                                 |
| **TOTALS**                                             |   | 35-40                Days                                                 |   |                                                                                                                                                                                                                                                                                                                                              |   | 20-30                Additional days                                                                                                                                                                 |

----

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**FEES      FOR ADDITIONAL SERVICES**

| Consulting                Level              |   | Daily                Rates                             |
|----------------------------------------------|--------|--------------------------------------------------------|
| Analyst                                      |   | $                      * |
| Consultant                                   |   | $                      * |
| Sr.                Consultant                |   | $                      * |
| Manager                                      |   | $                      * |
| Sr.                Manager                   |   | $                      * |
| Director                                     |   | $                      * |
| Sr.                Medical Director          |   | $                      * |
| Vice                President                |   | $                      * |
| VP,                National Medical Director |   | $                      * |

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**PMPM      RATE SCHEDULE **

**FOR      SIGNIFICANT CHANGES IN THE COVERED POPULATION**

| *Covered                Population* |   | *Incremental                Data PMPM Fees*      |   | *Non-Incremental                Data PMPM Fees*  |
|-------------------------------------|--------|--------------------------------------------------|--------|--------------------------------------------------|
|                                |   |                                             |   |                                             |
| 100,000-199,999                     |   | $                     * |   | $                     * |
| 200,000-299,999                     |   | $                     * |   | $                     * |
| 300,000-399,999                     |   | $                     * |   | $                     * |
| 400,000-499,999                     |   | $                     * |   | $                     * |
| 500,000-599,999                     |   | $                     * |   | $                     * |
| 600,000-699,999                     |   | $                     * |   | $                     * |
| 700,000-799,999                     |   | $                     * |   | $                     * |
| 800,000-899,999                     |   | $                     * |   | $                     * |
| 900,000-999,999                     |   | $                     * |   | $                     * |
| 1,000,000-1,499,999                 |   | $                     * |   | $                     * |
| 1,500,000-1,999,999                 |   | $                     * |   | $                     * |
| 2,000,000-2,499,999                 |   | $                     * |   | $                     * |
| 2,500,000-3,500,000                 |   | $                     * |   | $                     * |
| 3,500,000-4,500,000                 |   | $                     * |   | $                     * |
| >                4,500,000       |   | $                     * |   | $                     * |

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