A yes/no response indicating Wellness Program whether the Varchar 1 No Offered (Y/N)? plan offers wellness program Select from dropdown: asthma, heart disease, depression, Identify disease diabetes, high management blood pressure Varchar 15 No programs offered and high cholesterol, low back pain, pain management, pregnancy Do you have Multiple multiple Provider Varchar 1 No Tiers (Y/N)?— provider tiers? What is the Expected expected Utilization for Tier percentage of Varchar 15 No 1? utilization for Tier 1? List all plan Plan Level level Varchar 15 No Exclusions exclusions. Cost–Sharing Changes in Reduction Plan Varchar 15 No Cost Sharing Variation
Wellness Program Offered (Y/N)? A yes/no response indicating whether the plan offers wellness program Varchar 1 No Identify disease management programs offered Select from dropdown: asthma, heart disease, depression, diabetes, high blood pressure and high cholesterol, low back pain, pain management, pregnancy Varchar 15 No Multiple Provider Tiers (Y/N)?— Do you have multiple provider tiers? Varchar 1 No Expected Utilization for Tier 1? What is the expected percentage of utilization for Tier 1? Varchar 15 No Plan Level Exclusions List all plan level exclusions. Varchar 15 No Cost–Sharing Reduction Plan Variation Changes in Cost Sharing Varchar 15 No
TPA-Integration-Package07242013.docx