gaamend5.htm


    Back to Form 8-K

    Exhibit 10.3


    
      AMENDMENT
#5 TO CONTRACT NO. 0654 BETWEEN

    

    
      GEORGIA
DEPARTMENT OF COMMUNITY HEALTH AND

    

    
      WELLCARE
OF GEORGIA, INC.

    

    
      


    

    
      This Amendment is between the Georgia
Department of Community Health (hereinafter referred to as "DCH" or the
"Department") and WellCare of Georgia, Inc. (hereinafter referred to
as
"Contractor") and is made effective this 15th day of September ,  2008
(hereinafter referred
to as the "Effective Date"). Other than the changes, modifications and additions
specifically articulated in this Amendment #5 to Contract # 0654,
RFP#41900-001-0000000027, the original Contract shall remain in effect and
binding on and against DCH and Contractor. Unless expressly modified or added in
this Amendment #5, the terms and conditions of the original Contract are
expressly incorporated into this Amendment #5 as if completely restated
herein.

    

    
      


    

    
      WHEREAS, DCH and Contractor executed a contract
for the provision of services to members of the Georgia Families
Program;

    

    
      


    

    
      WHEREAS, DCH pays Contractor a per member per
month capitation rate for each Georgia Families member enrolled in the
Contractor's plan;

    

    
      


    

    
      WHEREAS, DCH has sought permission from the
Centers for Medicare and Medicaid Services (hereinafter referred to as "CMS") to
revise the capitation rates payable to Contractor for State Fiscal Year 2009;
and

    

    
      


    

    
      WHEREAS, pursuant to Section 32.0, Amendments in Writing, DCH and
Contractor desire to amend the above-referenced Contract by adding additional
funding as set forth below.

    

    
      


    

    
      NOW
THEREFORE, for and in consideration of the mutual promises of the
Parties, the terms, provisions and conditions of this Amendment and other good
and valuable consideration, the sufficiency of which is hereby acknowledged, DC
11 and Contractor hereby agree as follows:

    

    
      


    

    
      
        	
                I.

              	
                Upon
      receiving written notice from CMS indicating that agency's approval of the
      revised capitation rates, the parties shall delete the current Attachment H, Capitation Payment, in its
      entirety and replace it with the new Attachment H, Capitation Payment, contained at Exhibit 1 to this
      Amendment.

              


      

    

    
       

    

    
      
        	
                II.

              	
                DCH
      and Contractor agree that they have assumed an obligation to perform the
      covenants, agreements, duties and obligations of the Contract, as modified
      and amended herein, and agree to abide by all the provisions, terms and
      conditions contained in the Contract as modified and
    amended.

              


      

    

    
      


    

    
      
        	
                III.

              	
                This
      Amendment shall be binding and inure to the benefit of the parties hereto,
      their heirs, representatives, successors and assigns. Whenever the
      provisions of this Amendment and the Contract are in conflict, the
      provisions of this Amendment shall take precedence and
      control.

              


      

    

    
      


    

    
      Amendment
#5

    

    
      Contract
#0654

    

    
      Page 1 of
4

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      
        	
                VI.

              	
                It
      is understood by the Parties hereto that, if any part, term, or provision
      of this Amendment or this entire Amendment is held to be illegal or in
      conflict with any law of this State, then DCH, at its sole option, may
      enforce the remaining unaffected portions or provisions of this Amendment
      or of the Contract and the rights and obligations of the parties shall be
      construed and enforced as if the Contract or Amendment did not contain the
      particular part, term or provision held to be
  invalid.

              


      

    

    
      


    

    
      
        	
                VII.

              	
                This
      Amendment shall become effective as stated herein and shall remain
      effective for so long as the Contract is in
  effect.

              


      

    

    
      


    

    
      
        	
                VIII

              	
                This
      Amendment shall be construed in accordance with the laws of the State of
      Georgia.

              


      

    

    
      


    

    
      
        	
                IX.

              	
                All
      other terms and conditions contained in the Contract and any amendment
      thereto, not amended by this Amendment, shall remain in full force and
      effect.

              


      

    

    
      


    

    
      - SIGNATURES ON THE
FOLLOWING PAGE -

    

    
       

      
        	 Amendment
      #5	 
	 Contract
      #0654	
                 Page 2 of
      4

              


      

      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

SIGNATURE
PAGE

    

    
      


    

    
      


    

    
      
        	
                 
      

              	
                IN WITNESS WHEREOF, DCH
      and Contractor, through their authorized officers and agents, have caused
      this Amendment to be executed on their behalf as of the date
      indicated.

              


      

    

    
      


    

    
      GEORGIA
DEPARTMENT OF COMMUNITY HEALTH

    

    
      


    

    
      


    

    
      	
              /s/
      Rhonda
      Medows                    
      

              Dr.
      Rhonda M. Medows, M.D.

              Commissioner

            	
              9/15/08                  
      

              Date

            


    

    
      


    

    
       

      WELLCARE
OF GEORGIA, INC.

    

    
      


    

    
      


    

    
      	
              /s/ Thomas L.
      Tran                         
      

              *SIGNATURE

            	
              9/12/08                  

              Date

            
	
               

              Thomas L. Tran, SVP
      & CFO

              Please
      Print/Type Name Here

            	 
      


    

    
      


    

    
      


    

    
      	 
      	
              _______________________________

              AFFIX
      CORPORATE SEAL HERE

              (Corporations
      without a seal, attach a Certificate of Corporate
    Resolution)

            


    

    
      


    

    
      	
              ATTEST:

            	
              /s/ Karen
      Mulroe                   
      

              **SIGNTAURE

            
	 
      	
               

              Secretary                                 

              TITLE

            


    

    
      


    

    
      


    

    
      ______________________________________________________________________

    

    
      * Must be
President, Vice President, CEO or Other Authorized Officer

    

    
      ** Must
be Corporate Secretary

    

    
       

    

    
      
        	 Amendment
      #5	 
	 Contract
      #0654	
                 Page 3 of
      4

              




    

    
      
        
        

        
          
             


          

          
             


            
              

            

          

          
             


          

        

EXHIBIT
1

    

    
       

      
        CONFIDENTIAL
- NOT FOR CIRCULATION 

        ATTACHMENT
H

      

      
 

    

    
      Attachment
H is a table displaying the contracted rates by rate cell for each contracted
region. These rates will be the basis for calculating capitation payments in
each contracted Region.

       

    

    
      (The
table is displayed on the following page.)


    

    
      


    

    
      
        	 Amendment
      #5	 
	 Contract
      #0654	
                 Page 4 of
      4

              


      

    

     

    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      	
              
                FY
      2009 CMO Rates

              

            	 
      	 
      	 
      
	 
      	 
      	 
      	 
      
	
              
                Region

              

            	
              
                Aid
      Category

              

            	
              
                Age/Gender
      Group

              

            	
              
                WellCare

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                  $                 1,668.19

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                  $                    185.45

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                  $                    118.26

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                6 -
      13 Years, Male and Female

              

            	
              
                  $                    107.95

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Female

              

            	
              
                  $                    169.51

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    128.19

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      - 44 Years, Female

              

            	
              
                $                    281.94

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      - 44 Years, Male

              

            	
              
                $                    304.78

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Female

              

            	
              
                $                    531.46

              

            
	
              
                Atlanta

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Male

              

            	
              
                $                    560.83

              

            
	
              
                Atlanta

              

            	
              
                PeachCare

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                    148.84

              

            
	
              
                Atlanta

              

            	
              
                PeachCare

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    155.46

              

            
	
              
                Atlanta

              

            	
              
                PeachCare

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                  $                    107.31

              

            
	
              
                Atlanta

              

            	
              
                PeachCare

              

            	
              
                6 -
      13 Years, Male and Female

              

            	
              
                $                    116.58

              

            
	
              
                Atlanta

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    135.47

              

            
	
              
                Atlanta

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    137.43

              

            
	
              
                Atlanta

              

            	
              
                Breast
      and Cervical Cancer

              

            	
              
                All
      Ages

              

            	
              
                $                 1,068.97

              

            
	
              
                Atlanta

              

            	
              
                Maternity
      Delivery/Kick Payment

              

            	 
      	
              
                  $                 6,030.11

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                0 -
      2 Months, Male and Female

              

            	
              
                $                 1,972.95

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    202.43

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                1-5
      Years, Male and Female

              

            	
              
                $                    123.94

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                6 -
      13 Years, Male and Female

              

            	
              
                $                    117.45

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    165.93

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    117.28

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      -44 Years, Female

              

            	
              
                $                    308.09

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      -44 Years, Male

              

            	
              
                $                    334.14

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Female

              

            	
              
                $                    589.81

              

            
	
              
                Central

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Male

              

            	
              
                $                    639.07

              

            
	
              
                Central

              

            	
              
                PeachCare

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                    143.83

              

            
	
              
                Central

              

            	
              
                PeachCare

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    148.43

              

            
	
              
                Central

              

            	
              
                PeachCare

              

            	
              
                1-5
      Years, Male and Female

              

            	
              
                $                    120.34

              

            
	
              
                Central

              

            	
              
                PeachCare

              

            	
              
                6 -
      13 Years, Male and Female

              

            	
              
                $                    127.15

              

            
	
              
                Central

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    153.25

              

            
	
              
                Central

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    135.15

              

            
	
              
                Central

              

            	
              
                Breast
      and Cervical Cancer

              

            	
              
                All
      Ages

              

            	
              
                $                 1,060.34

              

            
	
              
                Central

              

            	
              
                Maternity
      Delivery/Kick Payment

              

            	 
      	
              
                $                 6,182.35

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                 1,772.63

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    207.78

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                $                    131.99

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                6 -
      13 Years, Male and Female

              

            	
              
                $                    113.19

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14
      - 20 Years, Female

              

            	
              
                $                    178.26

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    114.49

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      - 44 Years, Female

              

            	
              
                $                    302.73

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      -44 Years, Male

              

            	
              
                $                    344.15

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Female

              

            	
              
                $                    591.19

              

            
	
              
                East

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Male

              

            	
              
                $                    651.54

              

            
	
              
                East

              

            	
              
                PeachCare

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                    148.84

              

            
	
              
                East

              

            	
              
                PeachCare

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    149.30

              

            
	
              
                East

              

            	
              
                PeachCare

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                $                    131.50

              

            
	
              
                East

              

            	
              
                PeachCare

              

            	
              
                6-13
      Years, Male and Female

              

            	
              
                $                    120.73

              

            
	
              
                East

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    147.22

              

            
	
              
                East

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    132.58

              

            
	
              
                East

              

            	
              
                Breast
      and Cervical Cancer

              

            	
              
                All
      Ages

              

            	
              
                $                 1,080.15

              

            
	
              
                East

              

            	
              
                Maternity
      Delivery/Kick Payment

              

            	 
      	
              
                $                 6,611.86

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                 1,736.43

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    219.15

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                $                    140.23

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                6-13
      Years, Male and Female

              

            	
              
                $                    142.46

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    204.52

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    180.34

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      - 44 Years, Female

              

            	
              
                $                    352.94

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      -44 Years, Male

              

            	
              
                $                    342.96

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Female

              

            	
              
                $                    622.97

              

            
	
              
                North

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Male

              

            	
              
                $                    653.17

              

            
	
              
                North

              

            	
              
                PeachCare

              

            	
              
                0 -
      2 Months, Male and Female

              

            	
              
                $                    149.87

              

            
	
              
                North

              

            	
              
                PeachCare

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    149.86

              

            
	
              
                North

              

            	
              
                PeachCare

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                $                    119.50

              

            
	
              
                North

              

            	
              
                PeachCare

              

            	
              
                6-13
      Years, Male and Female

              

            	
              
                $                    128.24

              

            
	
              
                North

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    166.01

              

            
	
              
                North

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    147.86

              

            
	
              
                North

              

            	
              
                Breast
      and Cervical Cancer

              

            	
              
                All
      Ages

              

            	
              
                $                 1,073.79

              

            
	
              
                North

              

            	
              
                Maternity
      Delivery/Kick Payment

              

            	 
      	
              
                $                 6,439.10

              

            


    

    
       

      1 of
2

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    

    
      


    

    
      	
              
                FY
      2009 CMO Rates

              

            	 
      	 
      	 
      
	 
      	 
      	 
      	 
      
	
              
                Region

              

            	
              
                Aid
      Category

              

            	
              
                Age/Gender
      Group

              

            	
              
                WellCare

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                 1,802.33

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    204.33

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                $                    128.40

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                6 -
      13 Years, Male and Female

              

            	
              
                $                    121.09

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14
      - 20 Years, Female

              

            	
              
                $                    168.90

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    129.17

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      - 44 Years, Female

              

            	
              
                $                    316.15

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      - 44 Years, Male

              

            	
              
                $                    309.92

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Female

              

            	
              
                $                   615.18

              

            
	
              
                Southeast

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Male

              

            	
              
                $                    635.83

              

            
	
              
                Southeast

              

            	
              
                PeachCare

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                    149.21

              

            
	
              
                Southeast

              

            	
              
                PeachCare

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    149.92

              

            
	
              
                Southeast

              

            	
              
                PeachCare

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                $                    125.86

              

            
	
              
                Southeast

              

            	
              
                PeachCare

              

            	
              
                6-13
      Years, Male and Female

              

            	
              
                $                    130.78

              

            
	
              
                Southeast

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    152.22

              

            
	
              
                Southeast

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    128.13

              

            
	
              
                Southeast

              

            	
              
                Breast
      and Cervical Cancer

              

            	
              
                All
      Ages

              

            	
              
                $                 1,113.87

              

            
	
              
                Southeast

              

            	
              
                Maternity
      Delivery/Kick Payment

              

            	 
      	
              
                $                 6,547.77

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                 1,885.03

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    227.05

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                $                    148.24

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                6 -
      13 Years, Male and Female

              

            	
              
                $                    121.01

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    187.98

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    122.89

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      -44 Years, Female

              

            	
              
                $                    337.89

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                21
      - 44 Years, Male

              

            	
              
                $                    309.41

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Female

              

            	
              
                $                    568.47

              

            
	
              
                Southwest

              

            	
              
                Medicaid
      (LIM/Refugee/RSM)

              

            	
              
                45+
      Years, Male

              

            	
              
                $                    676.55

              

            
	
              
                Southwest

              

            	
              
                PeachCare

              

            	
              
                0-2
      Months, Male and Female

              

            	
              
                $                    142.53

              

            
	
              
                Southwest

              

            	
              
                PeachCare

              

            	
              
                3-11
      Months, Male and Female

              

            	
              
                $                    149.98

              

            
	
              
                Southwest

              

            	
              
                PeachCare

              

            	
              
                1 -
      5 Years, Male and Female

              

            	
              
                $                    133.79

              

            
	
              
                Southwest

              

            	
              
                PeachCare

              

            	
              
                6 -
      13 Years, Male and Female

              

            	
              
                $                    131.36

              

            
	
              
                Southwest

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Female

              

            	
              
                $                    149.19

              

            
	
              
                Southwest

              

            	
              
                PeachCare

              

            	
              
                14-20
      Years, Male

              

            	
              
                $                    123.69

              

            
	
              
                Southwest

              

            	
              
                Breast
      and Cervical Cancer

              

            	
              
                All
      Ages

              

            	
              
                $                 1,097.88

              

            
	
              
                Southwest

              

            	
              
                Maternity
      Delivery/Kick Payment

              

            	 
      	
              
                $                 6,070.34

              

            


    

    
      


    

    
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