EX-10.25.3






JEB BUSH, GOVERNOR ALAN LEVINE, SECRETARY



March 15, 2005




Mr. Mitch Wright


Amerigroup Florida, Inc.
4425 Corporation Lane
Virginia Beach, FL 23462



Dear Mr. Wright:



Enclosed is an executed copy of Amendment No. 4 to AHCA Contract No. FA523, Health Care Services
to Medicaid Beneficiaries (HMO), for your records. Should you have any questions I may be
contacted at (850) 414 — 7653.




Sincerely,




/s/ Barbara B. Vaughan




	 	 	 	Barbara B. Vaughan, Mgmt. Review Specialist Procurement Office





BBV/bv



Enclosures



cc: Christina Lopez, AHCA Contract Manager, MS #50



	 	 	 
	2727 Mahan Drive • Mail Stop #15

Tallahassee, FL 32308

	 	Visit AHCA online at

ahca.myflorida.com







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AHCA CONTRACT NO. FA523




AMENDMENT NO. 4




THIS CONTRACT, entered into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE
ADMINISTRATION, hereinafter referred to as the “Agency” and AMERIGROUP OF FLORIDA, INC.,
hereinafter referred to as the “Vendor”, is hereby amended as follows:



WHEREAS, the Vendor’s name has been referenced as Amerigroup of Florida, Inc. throughout the
Contract and its attachments.



WHEREAS, Amerigroup of Florida, Inc. is not the correct name of the Vendor, the correct name
being “Amerigroup Florida, Inc.”



NOW, THEREFORE, the Contract and its attachments are hereby amended to reflect the correct
Vendor name.



1. The Vendor name is hereby amended from Amerigroup of Florida, Inc. to Amerigroup Florida, Inc.



2. Standard Contract, Section ILA, Contract Amount, the first sentence is hereby amended to now
read:




To pay for contracted services according to the conditions of Attachment I in an amount not to
exceed $663,357,697.00 (an increase of $4,531,502.00), subject to the availability of funds.




	 	3.	 	Effective March 1, 2005, Attachment I, section 90.0, Payment and Authorized Enrollment
Levels, Table 2, Area 07 is hereby amended to read as follows:





Table 2



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Area 07 General Rates plus Mental Health Plan -
	 	015005308(ORANGE) 015005313(SEMINOLE)
	 	015005314(OSCEOLA)
	 	 	 	 
	 
	 	<1 year	 	 	1-5	 	 	 	6-13	 	 	14-20 Male	 	14-20 Female	 	21-54 Male	 	21-54 Female	 	 	55-64	 	 	 	65+	 
	TANF/FC/SOBRA
	 	 	337.20	 	 	 	76.92	 	 	 	58.07	 	 	 	59.10	 	 	 	114.69	 	 	 	136.45	 	 	 	206.32	 	 	 	287.87	 	 	 	287.87	 
	SSI/No Medicare
	 	 	3217.90	 	 	 	406.84	 	 	 	260.45	 	 	 	239.73	 	 	 	239.73	 	 	 	628.24	 	 	 	628.24	 	 	 	594.96	 	 	 	594.96	 
	SSI/Part B
	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 	 	 	266.03	 
	SSI/Part A & B
	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	293.59	 	 	 	208.25	 








	 	4.	 	Attachment I, Section 90.0, Payment and Authorized Enrollment Levels, Table 3, the second
paragraph is hereby amended to now read:






Notwithstanding the payment amounts which may be computed with the above rate table, the sum of
total capitation payments under this contract shall not exceed the total contract amount of
$663,357,697.00 (an increase of $4,531,502.00), expressed on page seven of this contract.




	 	5.	 	This amendment shall begin on March 1, 2005, or the date on which the amendment has been
signed by both parties, whichever is later.





All provisions in the Contract and any attachments thereto in conflict with this amendment
shall be and are hereby changed to conform with this amendment.



All provisions not in conflict with this amendment are still in effect and are to be performed
at the level specified in the Contract.




	 	 	 	This amendment and all its attachments are hereby made a part
of the Contract. AHCA Contract No. FA523, Amendment No. 4, Page 1
of 2	 





AHCA Form 2100-0002 (Rev. NOV03)



2




This amendment cannot be executed unless all previous amendments to this Contract
have been fully executed.



IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment (including all
attachments) to be executed by their officials thereunto duly authorized.



	 	 	 
	AMERIGROUP FLORIDA, INC.	 	STATE OF FLORIDA, AGENCY FOR HEALTH CARE
	 	 	ADMINISTRATION
	SIGNED

BY: /s/ Don Gilmore

	 	SIGNED

BY:
	 

	 	

	 
	 	 
	NAME: Don Gilmore

TITLE: CEO

	 	NAME: Alan Levine

TITLE: Secretary
	 

	 	 
	DATE: 2/28/05

	 	DATE:
	 

	 	 








	 	 	 	REMAINDER OF PAGE INTENTIONALLY LEFT BLANK





AHCA Contract No. FA523, Amendment No. 4, Page 2 of 2




AHCA Form 2100-0002 (Rev. NOV03)



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This amendment cannot be executed unless all previous amendments to this Contract
have been fully executed.



IN WITNESS WHEREOF, the parties hereto have caused this 2 page amendment (including all
attachments) to be executed by their officials thereunto duly authorized.



	 	 	 	 	 
	AMERIGROUP FLORIDA, INC.	 	STATE OF FLORIDA, AGENCY FOR HEALTH
	 	 	CARE ADMINISTRATION	 	 
	SIGNED

BY:

	 	SIGNED

BY: /s/Alan Levine
	 	



	
 
	 	 
	 	 
	NAME: Don Gilmore

	 	NAME: Alan Levine
	 	

	 

	 	

	 	

	TITLE:CEO

	 	TITLE: Secretary
	 	

	 

	 	 
	 	 
	DATE:

	 	DATE: 2/28/05
	 	

	
 
	 	 
	 	 








	 	 	 	REMAINDER OF PAGE INTENTIONALLY LEFT BLANK





AHCA Contract No. FA523, Amendment No. 4, Page 2 of 2




AHCA Form 2100-0002 (Rev. NOV03)




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