Exhibit
10.131


 


AMENDMENT TO

CALIFORNIACARE MEDICAL SERVICES AGREEMENT

BETWEEN

BLUE CROSS OF CALIFORNIA

AND

PROSPECT MEDICAL GROUP


 


This Amendment to the CaliforniaCare Medical Services Agreement is
entered into at Woodland Hills, Los Angeles County, California, and will be
effective as of January 1, 2001 between Blue Cross of California and its
Affiliates (“BLUE CROSS”) and Prospect Medical Group (“PARTICIPATING MEDICAL
GROUP”).


 


RECITALS


 


A.           BLUE
CROSS and PARTICIPATING MEDICAL GROUP have previously entered into a
CaliforniaCare Medical Services Agreement, effective January 1, 1997, as
may have been amended (“Agreement”).


 


B.             The
parties now desire to amend the Agreement.


 


NOW, THEREFORE, IT IS AGREED:


 


1.               All
references in the Agreement to the Department of Corporations and the
Commissioner of Corporations shall hereafter mean the California Department of
Managed Health Care and the Director of the California Department of Managed
Health Care, respectively.


 


2.               The
following Sections 2.09.1 and 2.37.1 are hereby added to Article II of the
Agreement:


 


2.09.1                  “BLUE CROSS Services” means all
CALIFORNIACARE Covered Medical Services which are designated in this Agreement
or in the Division of Financial Responsibility as BLUE CROSS Services.


 


2.37.1                  “Mental Health Parity Services” means
those mental health services related to the diagnosis and Medically Necessary
treatment of “severe mental illnesses” and “serious emotional disturbances of a
child,” as such terms are defined in Section 1374.72
of the California Health and Safety Code.


 


3.               Section 2.23
of the Agreement is hereby deleted in its entirety and replaced with the
following:


 


“Emergency” means a sudden onset of a medical condition manifesting
itself by acute symptoms of sufficient severity (including, without limitation,
sudden and unexpected severe pain) such that the patient may reasonably believe
that the absence of immediate medical or psychiatric attention could reasonably
result in any of the following:


 


A.           Placing
the patient’s health in serious jeopardy,


 


B.             Serious
impairment to bodily functions,


 


C.             Other
serious medical or psychiatric consequences, or


 


D.            Serious
and/or permanent dysfunction of any bodily organ or part.


 


 












*** Confidential Information omitted and filed separately with the
Securities and Exchange Commission.


 


1

















 


4.               Section 2.42 of the Agreement is hereby
deleted and replaced with the following:


 


“Operations Manual” means the CaliforniaCare PMG Operations Manual, as
found on BLUE CROSS’ Internet web site at www.bluecrossca.com.


 


5.               Section 4.05C
of the Agreement is hereby amended and replaced in its entirety with the
following:


 


PARTICIPATING MEDICAL GROUP shall:


 


(1)          Make available to BLUE CROSS all minutes and notes from any and all Utilization
Management Committees and/or activities which relate to Members.


(2)          Make available to BLUE CROSS upon request all composite Utilization
Management data which include Members in the composite data set and provide
such detail as is available regarding those Members.


(3)          Provide the BLUE CROSS Medical Director (or the Medical Director’s
clinical designee) with a schedule designating the time and place of all
Utilization Management Committee meetings that relate to Members, in order that
he or she shall, in the Medical Director’s discretion, attend.  The BLUE CROSS Medical Director shall notify
PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not
be excluded from any deliberation on activities related to Members.


(4)          Comply with all applicable laws and regulations concerning utilization
management criteria and processes, including, without limitation, California Health and Safety Code Sections 1363.5 and
1367.01.


 


6.               Section 4.06
of the Agreement is hereby amended to add the following sentence to the
beginning of such Section:


 


PARTICIPATING MEDICAL GROUP agrees to provide financial information to
BLUE CROSS or its designated agent and to meet any other financial requirements
that assist BLUE CROSS in maintaining the financial viability of its
arrangements for the provision of health care services in the manner described
in Section 1375.4 of the California
Health and Safety Code and applicable regulations.


 


7.               Section 4.10A
of the Agreement is hereby deleted in its entirety and replaced with the
following:


 


To accept any and all Members who select PARTICIPATING MEDICAL GROUP
until such time as PARTICIPATING MEDICAL GROUP shall have provided ninety (90)
days prior written notice to BLUE CROSS that it has reached its maximum capacity
as set forth in Section 16.08 herein, or that it anticipates reaching such
maximum within ninety (90) days from the date of the notice to BLUE CROSS.  The maximum capacity of PARTICIPATING
MEDICAL GROUP designated in Section 16.08 shall be reduced only upon
ninety (90) days written notice to BLUE CROSS provided that PARTICIPATING
MEDICAL GROUP demonstrates to BLUE CROSS’ reasonable satisfaction, that
PARTICIPATING MEDICAL GROUP is unable to provide, due to overcapacity, Covered
Medical Services to Members in accordance with BLUE CROSS guidelines as set
forth in the Operations Manual and Medical Policy Guidelines, and PARTICIPATING
MEDICAL GROUP has reached maximum capacity for all of its health maintenance
organization members.  The parties
acknowledge their understanding that enrollment from individual accounts, or
changes in selection of PARTICIPATING MEDICAL GROUP by Members, are not
entirely within the control of BLUE CROSS. 
Nothing in this Section shall require that BLUE CROSS reassign any
Members assigned to PARTICIPATING MEDICAL GROUP as of the effective date of the
ninety (90) day notice referenced herein.


 


2

















 


8.               Section 4.10E
of the Agreement is hereby amended to add the following paragraph to the beginning
of such Section:


 


BLUE CROSS will comply with all requirements of California Health and Safety Code Section 1395.6.  The BLUE CROSS Managed Care Network may be
sold, leased, transferred or conveyed to Other Payors, which may include
workers’ compensation insurers or automobile insurers.  BLUE CROSS will disclose upon initial
signing of this Agreement and within 30 days of receipt of a written request
from PARTICIPATING MEDICAL GROUP a summary of all Other Payors currently
eligible to pay the negotiated rates under this Agreement as a result of their
arrangement with BLUE CROSS.  BLUE CROSS
requires such Other Payors to actively encourage Covered Persons to use network
participating providers when obtaining medical care through the use of one or
more of the following: reduced copayments, reduced deductibles, premium
discounts directly attributable to the use of a participating provider,
financial penalties directly attributable to the non-use of a participating
provider, providing Covered Persons with the names, addresses and phone numbers
of participating providers in advance of their selection of a health care
provider through the use of provider directories, toll-free telephone numbers
and internet web site addresses.  In the
event BLUE CROSS enters into an arrangement with an Other Payor that does not
require such active encouragement of the use of the BLUE CROSS Managed Care
Network, PARTICIPATING MEDICAL GROUP shall be allowed to decline to provide
services to such Other Payor.


 


9.               The
following Section 4.14 is hereby added to Article IV of the
Agreement:


 


4.14                           The parties agree that the
financial risk provisions of this Agreement have been negotiated and agreed to
by BLUE CROSS and PARTICIPATING MEDICAL GROUP.


 


10.         The following Sections 5.14.1 and 5.15.1 are hereby added to
Article V of the Agreement:


 


5.14.1                  To disclose information to PARTICIPATING
MEDICAL GROUP that enables PARTICIPATING MEDICAL GROUP to be informed regarding
the financial risk assumed under this Agreement, as required in California Health and Safety Code Section 1375.4
and applicable regulations.


 


5.15.1                  To authorize and arrange for the provision of
BLUE CROSS Services to Members for all new and renewing business.


 


11.         Section 7.01 shall be amended to read as follows:


 


Exhibits D, G, and G-1 (all incorporated by reference herein), set forth
Capitation payments for new and renewing business.  The applicable Capitation payment for each Member assigned to
PARTICIPATING MEDICAL GROUP, shall be paid monthly, prorated in accordance with
Member eligibility.


 


Such Capitation payment shall be adjusted for Member age, sex and
Benefit Agreement in accordance with age, sex and plan relativities that have
been developed by BLUE CROSS based upon actuarial assumptions and BLUE CROSS’
utilization experience.  BLUE CROSS
reserves the right to adjust such relativity factors, upon contract renewal,
based upon BLUE CROSS’ experience.


 


Effective January 1 2001, BLUE CROSS shall increase Capitation
rates in effect for 2000 for Durational Benefit Plans such as Plan “IC”
(“Individual Durational”) and Plan “L4” (“Small Group Durational”) for
PARTICIPATING MEDICAL GROUP by *** which rates shall remain in effect through
December 31, 2001.


 


Effective January 1 2002, BLUE CROSS shall increase Capitation
rates in effect for 2001 (excluding Durational Benefit Plans, AIM, CalKids, and
non-commercial products such as Workers’ Compensation, Medi-Cal and Medicare
Risk) for PARTICIPATING MEDICAL GROUP by *** which


 


3

















 


rates shall remain in effect through December 31, 2002.  Effective January 1, 2002, BLUE CROSS
shall increase Capitation rates in effect for 2001 for Durational Benefit Plans
such as Plan “IC” (“Individual Durational”) and Plan “L4” (“Small Group Durational”)
for PARTICIPATING MEDICAL GROUP by *** which rates shall remain in effect
through December 31, 2002.


 


Effective January 1 2003, BLUE CROSS shall increase Capitation
rates in effect for 2002 (excluding Durational Benefit Plans, AIM, CalKids, and
non-commercial products such as Workers’ Compensation, Medi-Cal and Medicare
Risk) for PARTICIPATING MEDICAL GROUP by ***which rates shall remain in effect through December 31,
2003.  Effective January 1, 2003,
BLUE CROSS shall increase Capitation rates in effect for 2002 for Durational
Benefit Plans such as Plan “IC” (“Individual Durational”) and Plan “L4” (“Small
Group Durational”) for PARTICIPATING MEDICAL GROUP by *** which rates shall
remain in effect through December 31, 2003.


 


Effective January 1 2004, BLUE CROSS shall increase Capitation
rates in effect for 2003 (excluding Durational Benefit Plans, AIM, CalKids, and
non-commercial products such as Workers’ Compensation, Medi-Cal and Medicare
Risk) for PARTICIPATING MEDICAL GROUP *** which rates shall remain in effect
through December 31, 2004. 
Effective January 1, 2004, BLUE CROSS shall increase Capitation
rates in effect for 2003 for Durational Benefit Plans such as Plan “IC”
(“Individual Durational”) and Plan “L4” (“Small Group Durational”) for PARTICIPATING
MEDICAL GROUP by *** which rates shall remain in effect through
December 31, 2004.


 


12.         The second paragraph of Section 9,04 of the Agreement is hereby
deleted and replaced in its entirety with the following:


 


BLUE CROSS shall accrue Non-Capitated Expenses by each PARTICIPATING
MEDICAL GROUP by the calendar year the services were incurred and paid through
March 31st after year-end. 
Beginning in year two (2) of this Agreement, any claims received after
calculation of the final Non-Capitated Performance Settlement will be charged
to the following year’s Non-Capitated Expenses.  Any Non-Capitated Service admissions, including, but not limited
to, inpatient hospital, skilled nursing facility, hospice and alternative
birthing center admissions that occur in one calendar year and extend into the
next year shall accrue to the year the admission occurred.  Notwithstanding the aforementioned, any
claims for Non-Capitated Services or Shared Risk Services (as defined in the
CALIFORNIACARE Medical Services Agreement in effect for years prior to the
Initial Term of this Agreement) paid after the March 31st immediately
following the effective date hereof will be charged to the Non-Capitated
Expense for the first calendar year, or portion thereof, of this Agreement.


 


13.         The third paragraph of Section 9.06B of the Agreement is hereby
deleted and replaced in its entirety with the following:


 


Within one hundred eighty (180) days after the end of BLUE CROSS’ fiscal
year, BLUE CROSS shall pay the Non-Capitated Performance Settlement if a
Non-Capitated Performance Settlement amount is due to PARTICIPATING MEDICAL
GROUP.


 


14.         The second paragraph of Section 10.01 of the Agreement is hereby
deleted and replaced in its entirety with the following:


 


BLUE CROSS shall accrue OPDE for each PARTICIPATING MEDICAL GROUP by the
calendar year the services were incurred and paid through March 31st after
year-end.  Beginning in year two (2) of
this Agreement, any claims received after calculation of the final Outpatient
Prescription Drug Settlement will be charged to the following year’s OPDE.  Notwithstanding the aforementioned, any
claims for outpatient prescription drug services incurred prior to the Initial
Term of this Agreement paid after the March 31st immediately following the
effective date hereof and if applicable, for subsequent years, will be charged
to the OPDE for the first calendar year of this Agreement, or portion thereof.


 


4

















 


15.         The second paragraph of
Section 10.03 of the Agreement is hereby deleted and replaced in its
entirety with the following:


 


The amount of the Outpatient Prescription
Drug Settlement and Formulary utilization incentive will be based on the
applicable PMPM Settlement calculation under Exhibit H multiplied by
PARTICIPATING MEDICAL GROUP’s Member Months for Members with outpatient
prescription drug benefits.  Within one
hundred eighty (180) days after the end of BLUE CROSS’ fiscal year, BLUE CROSS
will pay any Outpatient Prescription Drug Settlement that is due PARTICIPATING
MEDICAL GROUP for the previous year.


 


16.         Section 13.01 of the
Agreement is hereby deleted and replaced with the following


 


This Agreement shall be in effect for the
period January 1, 2001 through December 31, 2004.  Unless written notice of intent not to renew
or of intent to modify this Agreement is provided at least one hundred twenty
(120) days prior to December 31, 2004, this Agreement shall renew upon the
same terms and conditions for consecutive one year periods each year thereafter.


 


17.         Section II of
Exhibit A of the Agreement is hereby deleted in its entirety and replaced with
the following:


 


II.             Psychiatric Care
Benefits


 


Care shall be provided for (i) short-term
evaluation of the Member’s condition when such care is ordered by the attending
PARTICIPATING MEDICAL GROUP Physician and (ii) the diagnosis and medically
necessary treatment of “severe mental illnesses” and “serious emotional
disturbances of a child” as such terms are defined in California Health and Safety Code Section 1374.72.  Co-payments and limitations are as set forth
in the Member’s Benefit Agreement.  This
care shall not include visits for psychoanalysis.


 


18.         Exhibit A(l) of the
Agreement is hereby amended to delete in its entirety the categories of
“Chemical Dependency Rehabilitation,” “Detoxification” and “Mental Health
Services” and all provisions thereunder concerning financial responsibility for
the professional and facility components thereof and to replace them with the
following, respectively:


 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *CHEMICAL DEPENDENCY REHABILITATION

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Mental Health Services (Parity and
  Non-Parity)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Non-Mental Health Services 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DETOXIFICATION

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Mental Health Services (Parity and
  Non-Parity) 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Non-Mental Health Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH SERVICES (PARITY &
  NON-PARITY)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  * Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  * Inpatient Professional Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  * Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


5

















 


19.         Exhibit F.  Exhibit F, Non-Capitated
Performance Settlement Schedule, of the Agreement is hereby deleted and
replaced in its entirety with Exhibit F(2), Non-Capitated Performance
Settlement Schedule, attached hereto and incorporated herein by this
reference.  All references in the
Agreement to Exhibit F shall hereafter refer to such Exhibit F(2).


 


20.         Exhibit G, Section 11, Paragraph C of the Agreement is deleted in
its entirety and is hereby replaced with the following:


 


PARTICIPATING MEDICAL GROUP may elect to receive advance Supplemental
Capitation Payments prior to the time PARTICIPATING MEDICAL GROUP’s In-Network
Utilization Factor is known, i.e., during the applicable calendar quarter.  However, if at the end of such calendar
quarter, PARTICIPATING MEDICAL GROUP’s In-Network Utilization Factor is below
0.42, then BLUE CROSS shall have the right to set off the amount of advance
Supplemental Capitation Payments made during such quarter from Capitation
payments due PARTICIPATING MEDICAL GROUP in subsequent months.


 


Notwithstanding the above, after any quarterly adjustments are computed
by BLUE CROSS, PARTICIPATING MEDICAL GROUP shall receive no less than sixty
percent (60%) of Capitation rates, regardless of the In-Network Utilization
Factor for PARTICIPATING MEDICAL.


 


21.         Exhibit H.  Exhibit H, Outpatient
Prescription Drug Settlement Schedule, of the Agreement is hereby deleted
and replaced in its entirety with Exhibit H(3), Outpatient Prescription Drug
Settlement Schedule, attached hereto and incorporated herein by this
reference.  All references in the
Agreement to Exhibit H shall hereafter refer to such Exhibit H(3).


 


Upon
acceptance of the parties, this Amendment, as of the date specified on page one
hereof, shall become a part of this Agreement, and all provisions of the
Agreement not specifically inconsistent herewith shall remain in full force and
effect.


 


	
  BLUE CROSS OF CALIFORNIA

  	
   

  	
  PARTICIPATING MEDICAL GROUP

  
	
   

  	
   

  	
   

  
	
  /s/ Barry Ford

  	
   

  	
  /s/ Peter G. Goll

  
	
  Signature

  	
   

  	
  Signature

  
	
   

  	
   

  	
   

  
	
  Barry Ford

  	
   

  	
  Peter G. Goll

  
	
  Print
  Name

  	
   

  	
  Print
  Name

  
	
   

  	
   

  	
   

  
	
  V.P. Network Services

  	
  3-30-01

  	
   

  	
  Senior
  Vice President

  	
  2/28/01

  
	
  Title

  	
  Date

  	
   

  	
  Title

  	
  Date

  



 


6

















 


EXHIBIT F(2)


 


NON-CAPITATED PERFORMANCE SETTLEMENT SCHEDULE


For Non-Capitated Medical Services


For BLUE CROSS PLUS and CaliforniaCare


 


Based on Plan C,
$60,000 Stop Loss, Age/Sex Factor = 1.00 and Regional Factor = 1.00


 


Non-Capitated Performance
Settlement Calculation Method:


 


1)              Identify the
payment band that contains the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expense.


2)              Subtract the
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense from the high value of
the payment band


3)              Multiply the result
from Step 2 by the multiplier column for the payment band


4)              Add the result from
Step 3 to the minimum payment amount for the payment band to get the PMPM
Non-Capitated Performance Settlement


5)              Multiply the PMPM
Non-Capitated Performance Settlement from Step 4 by the PARTICIPATING MEDICAL
GROUP’s Member Months to calculate the Non Capitated Performance Settlement


 


	
   

  	
   

  	
  Non-Capitated
  Expense Ranges

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  (PMPM
  Non-Capitated Expense)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Payment Bands

  	
   

  	
  Low

  	
   

  	
  High

  	
   

  	
  Multiplier

  	
   

  	
  Minimum
  Payment Amount

  	
   

  
	
  1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0

  	
  %

  	
  ***

  	
   

  
	
  2

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  25

  	
  %

  	
  ***

  	
   

  
	
  3

  	
   

  	
  ***

  	
   

  	
  ****

  	
   

  	
  40

  	
  %

  	
  ***

  	
   

  
	
  4

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  55

  	
  %

  	
  ***

  	
   

  
	
  5

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  65

  	
  %

  	
  ***

  	
   

  
	
  6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  75

  	
  %

  	
  ***

  	
   

  
	
  7

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  65

  	
  %

  	
  ***

  	
   

  
	
  8

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  50

  	
  %

  	
  ***

  	
   

  
	
  9

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  40

  	
  %

  	
  ***

  	
   

  
	
  10

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0

  	
  %

  	
  ***

  	
   

  



 












* Attachment Point


 


Example of Non-Capitated
Performance Settlement Calculation


 


Assume: PARTICIPATING MEDICAL
GROUP has an PMPM Non-Capitated Expense of ***; and there are 100,000 member
months


 


(1)                                  Identify the
payment band that contains the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expense.


 


The PARTICIPATING MEDICAL
GROUP’s PMPM Non-Capitated Expense of *** falls between the low and high values
of payment band 7


 


(2)          Subtract the
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense from the high value
for the payment band.


***


 


(3)          Multiply the result
from Step 2 by the multiplier for the payment band.


***


 


(4)          Add the result from
Step 3 to the minimum payment amount for the payment band to get the PMPM
Non-Capitated Performance Settlement.  

*** PMPM Non-Capitated Performance Settlement


 


(5)          Multiply the PMPM
Non-Capitated Performance Settlement from Step 4 by the PARTICIPATING MEDICAL
GROUP’s Member Months to calculate the
Non-Capitated                 Performance
Settlement.


 


*** PMPM
Non-Capitated Performance Settlement x 100,000 member months = ***
Non-Capitated Performance Settlement


 

















 


EXHIBIT H(3)


 


OUTPATIENT PRESCRIPTION DRUG SETTLEMENT SCHEDULE


 


PMPM Outpatient Prescription Drug Expense
Target:      $11.29 PMPM


 


	
  PMPM Expense Range

  	
   

  	
  Settlement
  Calculation

  	
   

  	
  PMPM
  Settlement Maximum

  	
   

  
	
  Greater than ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  *** to ***

  	
   

  	
  (*** - PMPM OPDE) x 45%

  	
   

  	
  ***

  	
   

  
	
  *** to ***

  	
   

  	
  (*** - PMPM OPDE) x 50%

  	
   

  	
  ***

  	
   

  
	
  Less than ***

  	
   

  	
  *** PMPM

  	
   

  	
  ***

  	
   

  



 


If PARTICIPATING MEDICAL GROUP’s
PMPM OPDE is less than the OPDE Target, an additional $0.10 PMPM will be due to
PARTICIPATING MEDICAL GROUP if PARTICIPATING MEDICAL GROUP’s Formulary
utilization is equal to or greater than 95%.


 


	
  Formulary Utilization:

  	
   

  	
  Is the quotient of the number of
  prescriptions for Members with outpatient prescription drug benefits assigned
  to PARTICIPATING MEDICAL GROUP using drugs listed in the Blue Cross of
  California Outpatient Prescription Drug Formulary divided by the total number
  of prescriptions for Members with outpatient prescription drug benefits
  assigned to PARTICIPATING MEDICAL GROUP.

  



 


(Non-CAP)


 


2