EXHIBIT 6.15
CERTAIN INFORMATION IN THIS EXHIBIT IS SUBJECT TO A REQUEST FOR CONFIDENTIAL
TREATMENT. IN ACCORDANCE WITH RULE 24B-2 UNDER THE SECURITIES EXCHANGE ACT
OF 1934, AS AMENDED, SUCH INFORMATION HAS BEEN OMITTED AND FILED SEPARATELY
WITH THE SECURITIES AND EXCHANGE COMMISSION. THE LOCATION OF SUCH OMITTED
INFORMATION HAS BEEN INDICATED WITH AN ASTERISK (*).
ADVANTAGE CARE NETWORK, INC.
PROVIDER AGREEMENT
This agreement is between a health services provider (MEDICAL PROVIDER) and
ADVANTAGE CARE NETWORK, INC., (ACN). The purpose of this agreement is to
define the responsibilities of the MEDICAL PROVIDER for contracts and
agreements that may be entered into by ACN on behalf of the MEDICAL PROVIDER.
ADVANTAGE CARE NETWORK, INC., (hereinafter referred to as "ACN") and MEDIQUIK
SERVICES, INC. (hereinafter referred to as "MEDICAL PROVIDER"), are mutually
desirous of entering into this agreement whereby the MEDICAL PROVIDER
participates in and makes available certain medical and related services or
products to Health Care Service Organizations, Preferred Provider
Organizations, Exclusive Provider Networks and other medical delivery systems
(hereinafter collectively referred to as "HEALTH PLANS"), under agreements
and arrangements negotiated by the ACN.
WHEREAS, the ACN is a Texas Corporation organized by the physicians to
arrange for or administer the provision of health care services by
contracting directly or indirectly with Payors, Employers, Insurers and
others;
WHEREAS, the ACN obtains contracts with MEDICAL PROVIDERS, physicians,
hospitals and other health care practitioners and entities to arrange for or
administer at pre-determined rates, the delivery of such health care services;
WHEREAS, the MEDICAL PROVIDER is a Health Care Professional or business
licensed in the State and is qualified to provide health care goods or
services to Beneficiaries in El Paso, Texas.
THEREFORE, the ACN and MEDICAL PROVIDER agree to abide by and be governed by
all conditions set forth in this agreement including the Parties Obligations,
Attachments and any Exhibits or Amendments.
In consideration of the mutual promises herein, the parties agree as follows:
I. DEFINITIONS
"BENEFICIARY" means any individual, or eligible dependent of such
individual, whether referred to as "Insured", "Subscriber", "Member",
"Participant", "Enrollee", "Dependent" or otherwise, who is eligible for
Covered Services pursuant to a Service Agreement that is entered into by
ACN.
"COINSURANCE" means a payment that a Beneficiary is required to make to a
Health Care Professional for Covered Services under a Service Agreement,
which is calculated as a percentage of the contracted reimbursement rate of
such services.
"CONTRACTOR" means the Advantage Care Network, Inc. sometimes referred to
as the (ACN), and its corporate Board of Directors.
"COPAYMENT OR DEDUCTIBLE" means a payment that a Beneficiary is required to
make to a Health Care Professional under a Service Agreement, which is
calculated, as a fixed dollar payment.
"COVERED SERVICES" means those health care services provided to a
Beneficiary in accordance with a Service Agreement.
"HEALTH CARE PROFESSIONAL" means a MEDICAL PROVIDER or any other health
care practitioner or entity that has a direct or indirect contractual
arrangement with ACN to provide Covered Services.
"PARTICIPATING HOSPITAL" means a hospital that has a direct or indirect
contractual agreement with ACN and to which a Health Care Professional may
admit Beneficiary for care and treatment.
"PAYOR" means a person or entity that has entered into an agreement with
ACN to participate in the ACN for the purpose of making available, by
contract, health care services to its Beneficiaries. Payors may enter into
such an agreement through duly licensed third party administrators that
have been authorized and empowered to act as their attorney-in-fact to
enter into a Payor Participation Agreement.
"ACN" means the ADVANTAGE CARE NETWORK, INC., a physician developed
organization developed for the purpose of (a) soliciting third party payors
for health care services for participation in the ACN, (b) entering into
agreements with such third party payors, hospitals and other health care
facilities, and other entities owned and controlled by medical providers
and other health care professionals ("HCPs") in order to facilitate the
execution and performance of Payor Service Agreements and performing or
arranging for the performance of services such as utilization review,
provider credentialing, quality assurance services and claims processing.
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QUALITY ASSURANCE" means the process established and operated by the ACN or
its designee relating to the quality of Covered Services.
"SERVICE AGREEMENT" means those agreements between ACN and an employer,
insurer, labor union, trust or other organization or entity, that specifies
services to be provided to or for the benefit of, or arranged for or
reimbursed to, or for the benefit of Beneficiaries, the terms and
conditions under which those services are to be provided and/or reimbursed.
"MEDICAL PROVIDER" means a provider of health care services or products who
agrees to furnish Covered Services to Beneficiaries.
"UTILIZATION REVIEW" means the processes to review and determine whether
certain health care services provided or to be provided to Beneficiaries
are medically necessary and are provided in an effective and cost efficient
manner.
II. OBLIGATIONS
A. SERVICES
1. MEDICAL PROVIDER and ACN shall act in accordance with the terms
of this Agreement and applicable Attachments. MEDICAL PROVIDER
shall accept the negotiated rates set forth in Attachments to
this Agreement as payment in full for all services provided to
Beneficiaries pursuant to this Agreement. The ACN may negotiate
service agreements with different payors that may have different
reimbursement criteria. All ACN approved agreements shall
include reimbursement rates that shall become individual
attachments to this agreement.
2. MEDICAL PROVIDER shall provide or deliver Covered Services with
the same standard of care, skill and diligence customarily used
by similar Health Care Professionals in the community in which
such services are rendered. MEDICAL PROVIDER shall render
Covered Services in the same manner, in accordance with the same
standards, and with the same availability, as offered to other
patients. MEDICAL PROVIDER shall not differentiate or
discriminate in the treatment of any Beneficiary because of race,
color, national original, ancestry, religion, sex, marital
status, sexual orientation, age, health status or source of
payment.
3. MEDICAL PROVIDER shall provide services only at Participating ACN
Hospitals except in the case of an Emergency or as otherwise
required by law.
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4. For referrals and if applicable, MEDICAL PROVIDER shall refer
Beneficiary to Participating ACN Health Care Professionals except
in the case of an Emergency or as otherwise required by law.
5. MEDICAL PROVIDER shall be bound by and comply with the provisions
of applicable state and federal laws and regulations and MEDICAL
PROVIDER shall comply with the requirements of and shall
participate in Quality Assurance and Utilization Review.
6. ACN shall establish a system of Beneficiary identification,
communicate requirements to Participating Health Care
Professionals and identify Participating Health Care
Professionals to Payors and Beneficiaries.
7. ACN shall contract, directly or indirectly, with Payors who agree
to pay in accordance with this Agreement for Covered Services
rendered by MEDICAL PROVIDER.
B. COMPENSATION AND BILLING
1. MEDICAL PROVIDER shall receive payments for Covered Services as
set forth in the attachments to this Agreement. Compensation
arrangements and rates are set forth in applicable Attachments
and may vary by payor. All Compensation arrangements and those
arrangements that involve risk between the payor and the ACN or
MEDICAL PROVIDER shall be approved by the ACN. Specific detail
concerning risk sharing and distribution of deficit or excess
fund balances shall be included in the specific payor attachment
to this agreement.
2. MEDICAL PROVIDER's reimbursement for Covered Services shall be
the lesser of Health Care Professional's usual and customary
charge for the service provided, or the ACN's negotiated fee as
described in Attachments to this Agreement, less applicable
Copayments, Deductibles and Coinsurance. MEDICAL PROVIDER shall
xxxx for Covered Services according to the following:
3. MEDICAL PROVIDER shall submit claims on the appropriate claim
form for all Covered Services within sixty (60) days of the date
those services are rendered. Any amount owing under this
Agreement shall be paid within thirty (30) days after the receipt
of a complete claim, unless additional required information is
requested within the thirty (30) day period, or the claim
involves coordination of benefits.
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4. Payors shall agree to deduct any Copayments, Deductibles, or
Coinsurance required by the Service Agreement from payment due to
MEDICAL PROVIDER. Deduction of for the Copayment, Deductible or
Coinsurance shall be determined on the basis of the lesser of
MEDICAL PROVIDER's usual and customary charges and ACN's
negotiated fee schedule.
5. MEDICAL PROVIDER shall not charge Beneficiary for services denied
as not being Medically Necessary (defined herein), unless MEDICAL
PROVIDER has obtained a written waiver from the Beneficiary.
Such a waiver shall be obtained in advance of the provision of
those services. The waiver shall clearly state that the
Beneficiary acknowledges that such services are not Medically
Necessary and that the Beneficiary shall be responsible for
payment of charges for such services.
6. MEDICAL PROVIDER will look solely to designated Payor for
compensation for Covered Services except for Copayments,
Deductibles or Coinsurance. MEDICAL PROVIDER agrees that whether
or not there is any unresolved dispute for payment, that under no
circumstances will MEDICAL PROVIDER directly or indirectly make
any charges or claims, other than for Copayments, Deductibles or
Coinsurance against any Beneficiaries or their representatives
for Covered Services and that this provision survives termination
of this Agreement for services rendered prior to such
termination. Except for the collection of Copayments,
Deductibles or Coinsurance, only those services that are not
Covered Services may be billed directly to Beneficiary, subject
to limitations listed above. This paragraph is to be interpreted
for the benefit of Beneficiary and does not diminish the
obligation of Payor to make payments to MEDICAL PROVIDER
according to the terms of this Agreement.
7. The following provisions apply regarding coordination of
benefits:
a. When designated Payor is primary under applicable
coordination of benefits rules, ACN or Payor shall pay
benefits as set forth in this Agreement without regard to
the obligations of any secondary payor.
b. When designated Payor is determined to be secondary to any
other payor, ACN or Payor will pay no greater amount than
the difference between the amount payable to MEDICAL
PROVIDER by the primary payor and the amount for Covered
Services owing under this Agreement. Payor shall not be
liable for any amount unless Payor has received MEDICAL
PROVIDER's claim for such secondary payment within
ninety (90) days of the date when Payor is determined to be
secondary.
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c. Where another payor is primary under coordination of
benefits rules, MEDICAL PROVIDER shall follow that payor's
billing rules.
8. MEDICAL PROVIDER may xxxx an individual directly for any services
provided following the date the individual ceases to be a
Beneficiary. Designated Payor has no obligation under this
Agreement to pay for services rendered to individuals who no
longer are Beneficiaries.
C. RECORDS
1. ACN AND MEDICAL PROVIDER agree that clinical records of
Beneficiaries shall be regarded as confidential and both shall
comply with all applicable federal and state laws and regulations
regarding access and retention of such records.
2. MEDICAL PROVIDER shall maintain and furnish such records and
documents as may be required by applicable laws and regulations.
Review, as required by Payor.
3. MEDICAL PROVIDER shall provide ACN or its designee with
reasonable access during regular business hours to specified
clinical and medical records of Beneficiaries maintained by
MEDICAL PROVIDER for the period required by applicable law and at
any time thereafter that such access is reasonably required in
connection with a Beneficiary's health care.
4. Designated Payor shall be responsible for obtaining Beneficiary's
consent to the release of medical record information by MEDICAL
PROVIDER for the purposes stated in this section, and such Payor
shall indemnify and hold harmless MEDICAL PROVIDER for any claim
by a Beneficiary for breach of confidentiality resulting from
MEDICAL PROVIDER's compliance with this section.
D. INSURANCE AND LIABILITY
1. Throughout the term of this Agreement, MEDICAL PROVIDER shall
maintain at MEDICAL PROVIDER's expense general and professional
liability coverage in a form and amount acceptable to ACN.
MEDICAL PROVIDER shall give ACN a certificate of insurance
evidencing such coverage upon request. MEDICAL PROVIDER shall
give ACN thirty (30) days prior written notice of cancellation,
modification or termination of such insurance. MEDICAL PROVIDER
shall give ACN prompt written notice of any claims against
MEDICAL PROVIDER's liability coverage.
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2. Neither party hereto shall be liable for defending or for the
expense of defending the other party, its agents, or employees,
against any claim, legal action, dispute resolution or
administrative or regulatory proceeding arising out of or related
to such other party's actions or omissions under this Agreement.
Neither party hereto shall be liable for any liability of the
other party, its agents, or employees, whether resulting from
judgment, settlement, award, fine or otherwise, which arises out
of such other party's actions or omissions under this Agreement.
E. UTILIZATION REVIEW
1. ACN shall establish or contract for Utilization Review, which
shall seek to assure that Covered Services compensated under the
Service Agreement are Medically Necessary. "Medically Necessary"
means services or supplies which, under the provisions of this
Agreement, are determined by the ACN under Utilization review to
be: (a) appropriate and necessary for the symptoms, diagnosis or
treatment of the medical condition; (b) provided for diagnosis or
direct care and treatment of the medical condition; within
standards of good medical practice within the organized medical
community and (d) not primarily for the convenience of the
Beneficiary, the Beneficiary's Health Care Professional or
another provider. Except as otherwise provided in a Service
Agreement, Covered Services must be Medically Necessary.
F. INSPECTIONS
1. Upon reasonable notice and at reasonable hours, ACN or its agents
may inspect MEDICAL PROVIDER's premises and operations to ensure
that they are adequate to meet Beneficiary's needs.
G. REPRESENTATIONS
1. MEDICAL PROVIDER represents and warrants that the information set
forth in the ACN's Credentialing Application is true and correct.
MEDICAL PROVIDER shall promptly notify ACN of any changes in the
information contained in the Application within thirty (30) days
of such change.
2. ACN makes no representations or guarantees concerning the number
of Beneficiaries it can or will refer to MEDICAL PROVIDER under
this Agreement.
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H. XXX-XXXXXXXXXX
0. MEDICAL PROVIDER shall not discuss any information concerning
rates, terms or negotiations concerning this Agreement with other
parties unless prior approval has been provided by the ACN Board
of Directors.
III. MISCELLANEOUS OBLIGATIONS
A. CONTRACTOR RELATIONSHIP
1. This Agreement is intended to create a relationship between ACN
and MEDICAL PROVIDER for the purpose of effecting these
provisions.
2. Nothing in this Agreement, including MEDICAL PROVIDER's
participation in the Quality Assurance and Utilization Review
process, shall be construed to interfere with or in any way
affect MEDICAL PROVIDER's obligation and responsibility to
exercise independent medical judgment in rendering health care
services or goods to Beneficiaries.
B. TERM OF AGREEMENT
1. The initial term of this Agreement shall begin on the Effective
Date and shall continue from year to year thereafter, unless
terminated as set forth below.
C. TERMINATION
1. FOR CAUSE. MEDICAL PROVIDER or ACN may terminate this Agreement
at any time for cause. Cause for termination includes, but is
not limited to, the following:
a. Failure of ACN to maintain licenses or certifications
required to operate in conformity with this Agreement.
b. Habitual neglect or continued failure by either party to
perform its duties under this Agreement.
c. Initiation of bankruptcy proceedings by or against either
party.
d. Material breach of this Agreement by either party.
e. Failure by MEDICAL PROVIDER to maintain licenses required to
perform MEDICAL PROVIDER's duties under this Agreement, or
to comply with applicable laws and regulations.
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f. Any misrepresentation or falsification of any information on
MEDICAL PROVIDER's application submitted to ACN.
g. Any suspension or other involuntary termination or reduction
of MEDICAL PROVIDER's privileges.
h. Commission or omission of any act or any conduct or
allegation of conduct for which MEDICAL PROVIDER's license
and certification may be subject to revocation or
suspension, whether or not actually revoked or suspended, or
if MEDICAL PROVIDER is otherwise disciplined by any
licensing, regulatory, professional entity or any
professional organization with jurisdiction over MEDICAL
PROVIDER.
i. Failure of MEDICAL PROVIDER to maintain required liability
coverage protection.
j. Any occurrence under paragraph (e) through (j) above shall
be grounds for immediate termination. Termination for any
other reason set forth above shall be upon thirty (30) day's
prior written notice by the terminating party.
2. WITHOUT CAUSE. This Agreement may be terminated at any time
without cause or prejudice upon sixty (60) days prior written
notice by either party.
D. RIGHTS AND OBLIGATIONS UPON TERMINATION
1. Upon termination of this Agreement for any reason, the rights of
each party hereunder shall terminate. Any such termination,
however, shall not release MEDICAL PROVIDER or ACN from
obligations under this Agreement prior to the effective date of
termination.
E. ASSIGNMENT AND DELEGATION OF DUTIES
1. Neither ACN nor MEDICAL PROVIDER may assign duties, rights or
interests under this Agreement unless the other party shall so
approve by written consent.
F. USE OF NAME
1. MEDICAL PROVIDER agrees that MEDICAL PROVIDER's name, office
telephone number, address, specialty, board certification and
hospital
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affiliation, may be included in literature distributed to
existing or potential Beneficiaries, Participating Health Care
Professionals and Payors.
G. INTERPRETATION
1. The validity, enforceability and interpretation of this Agreement
shall be governed by any applicable federal law and by the laws
of Texas in which MEDICAL PROVIDER is licensed and has rendered
Covered Services.
H. AMENDMENT
1. ACN may amend this Agreement and Attachments by providing prior
written notice to MEDICAL PROVIDER. Failure of MEDICAL PROVIDER
to object in writing to any such proposed amendment within thirty
(30) days following receipt of notice shall constitute MEDICAL
PROVIDER's acceptance thereof. Notification to ACN of rejection
of any proposed amendment means that this Agreement shall remain
in force without the proposed amendment.
2. In the event that state or federal law or regulation should
change, alter or modify the present services, levels of payments
or standards of eligibility of Beneficiaries, such that the
terms, benefits and conditions of this Agreement must be changed
accordingly, then upon notice from ACN, MEDICAL PROVIDER shall
continue to perform services under this Agreement as modified.
3. Except as provided above, amendments to this Agreement shall be
agreed to in advance in writing by ACN and MEDICAL PROVIDER.
I. ENTIRE CONTRACT
1. This Agreement contains all the terms and conditions agreed upon
by the parties, and supersede all other agreements, express or
implied, regarding the subject matter.
J. NOTICE
1. Any notice required hereunder shall be in writing and shall be
sent by United States mail, postage prepaid, to ACN and MEDICAL
PROVIDER at the addresses set forth.
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K. ENFORCEABILITY AND WAIVER
1. The invalidity and non-enforceability of any term or provision of
this Agreement shall in no way affect the validity or
enforceability of any other term or provision. The waiver by
either party of a breach of any provision of this Agreement shall
not operate as or be construed as a waiver of any subsequent
breach thereof.
L. ARBITRATION
1. In the event any dispute should arise with regard to performance
or interpretation of any of the terms of this agreement, and the
dispute cannot be resolved by the ACN and MEDICAL PROVIDER, all
matters in controversy shall be submitted to arbitration pursuant
to the arbitration rules of the American Arbitration Association,
and such arbitration shall be held in Texas. Any decision
rendered in arbitration shall be binding and may be enforced in
any court or competent jurisdiction as provided by law.
M. INDEMNIFICATION
1. ACN shall indemnify and hold MEDICAL PROVIDER free and harmless
against any and all claims, demands, and expenses of all kinds
made against or incurred by ACN, which result or arise out of any
negligent act of ACN or any agent, employee or representative of
ACN in the performance or omission of any act or responsibility
assumed by the ACN pursuant to this agreement. MEDICAL PROVIDER
shall indemnify and hold ACN free and harmless against any and
all claims, demands, and expenses of all kinds made against or
incurred by MEDICAL PROVIDER, which result or arise out of any
negligent act of MEDICAL PROVIDER or any agent, employee or
representative of MEDICAL PROVIDER in the performance or omission
of any act or responsibility assumed by the MEDICAL PROVIDER
pursuant to this agreement.
MEDICAL PROVIDER ADVANTAGE CARE NETWORK (ACN)
Xxxxxxxx X. Xxxxxxxxx, Vice President Xxxxxxx Xxxxxxx, Vice President
------------------------------------- --------------------------------
TYPED NAME TYPED NAME
/s/ Xxxxxxxx X. Xxxxxxxxx /s/ Xxxxxxx Xxxxxxx
------------------------------------- --------------------------------
SIGNATURE SIGNATURE
6-29-99 effective 7-1-99
------------------------------------- --------------------------------
DATE DATE
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MEDIQUIK SERVICES, INC.
THE DIABETES ADVANTAGE PLAN PRICE SCHEDULE - EXHIBIT "A" - EFFECTIVE THRU
12/31/1999
SUPPLIES CODE ITEMS UM QTY PRICE
Bayer Elite Care System w/Glucometer E0607 1 EA 1 *
Bayer Elite Glucose Strips A4253 50 BX 1 *
Xxxxxx Cleanlet Lancets, 28 ga A4259 200 BX 1 *
Kendal Alcohol Prep Pad A4245 200 BX 1 *
Terumo Syringe 1/2cc 29x1/2 A4206 100 BX 1 *
Terumo Syringe 1cc 29x1/2 A4206 100 BX 1 *
Becton Xxxxxxxxx Syringe 1/2 cc 30 x 1/2 A4207 100 BX 1 *
Xxxxxxxx Xxxxxx Container 1qt A4211 1 EA 1 *
Becton Xxxxxxxxx HbA1c Test Kit 82948 1 EA 1 *
Becton Xxxxxxxxx HbA1c Lab Results 82947 1 EA 1 *
The price for supplies reflects a 90-day distribution shipping schedule. In the event that more frequent shipping schedules are
required, additional charges may occur.
MEDICATIONS (FORMULARY & PRICE EXAMPLES) TYPE RX TABS PRICE
Formulary: AWP minus 15% plus $1.50 dispensing charge
Acarbose Generic 50 mg 100 *
Acetohexamide Generic 250 mg 100 *
Chloropamide Generic 250 mg 100 *
Glimepiride Generic 2 mg 100 *
Glipizide Generic 5 mg 100 *
Glucophage Brand 500 mg 100 *
Glyburide Generic 5 mg 100 *
Insulin Brand 10 mg 100U *
Tolazamide Generic 250 mg 100 *
Tolbutamide Generic 500 mg 100 *
Troglitazone Generic 200 mg 30 *
Medications are ordered and billed pursuant to the physician's prescription. The AWP amount for each medication may vary as
manufacturers adjust prices. For any medication not listed above contact MediQuik for availability and the AVP amount.
SERVICES FREQUENCY PRICE
Patient Telephone Contact 1 every 3 mos *
Educational Materials 1 every 3 mos *
Access to Information re: Classes / Seminars various *
Internet Web Site Access 24 hrs *
Nurse On Call Services - (Immediate Family Only) 24 hrs *
Pharmacist On Call Services 24 hrs *
Program Reports 1 every 3 mos *
These services are available upon the enrollment of eligible patients in The Diabetes Advantage Plan.
BILLING PROCEDURE & PRICING EXAMPLES (see The Diabetes Advantage Plan Proposal)
Products and services are grouped and shipped as one package for each patient according to their planned shipping schedule. Based
upon the physician's orders, prescriptions and the patient's profile upon enrollment, the actual content and price of each package
may vary. Typically, a three months supply of the required items is forwarded to each patient. Shipping schedules may vary,
however, based upon insulin usage and the physician's requirements.
* This information has been omitted from this exhibit and is subject to a
request for confidential treatment. In accordance with Rule 24b-2 under the
Securities Exchange Act of 1934, as amended, such information has been filed
separately with the Securities and Exchange Commission.
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MEDIQUIK SERVICES, INC.
THE DIABETES ADVANTAGE PLAN PRICE SCHEDULE - EXHIBIT "A" - EFFECTIVE THRU
1/1/2000
SUPPLIES CODE ITEMS UM QTY PRICE
Bayer Elite Care System w/Glucometer E0607 1 EA 1 *
Bayer Elite Glucose Strips A4253 50 BX 1 *
Xxxxxx Cleanlet Lancets, 28 ga A4259 200 BX 1 *
Kendal Alcohol Prep Pad A4245 200 BX 1 *
Terumo Syringe 1/2cc 29x1/2 A4206 100 BX 1 *
Terumo Syringe 1cc 29x1/2 A4206 100 BX 1 *
Becton Xxxxxxxxx Syringe 1/2 cc 30 x 1/2 A4207 100 BX 1 *
Xxxxxxxx Xxxxxx Container 1qt A4211 1 EA 1 *
Becton Xxxxxxxxx HbA1c Test Kit 82948 1 EA 1 *
Becton Xxxxxxxxx HbA1c Lab Results 82947 1 EA 1 *
The price for supplies reflects a 90-day distribution shipping schedule and the net amount paid to MediQuik by the Payor. In the
event that more frequent shipping schedules are required, additional charges may occur.
MEDICATIONS TYPE RX TABS PRICE
Formulary: AWP minus 15% plus $1.50 dispensing charge
Acarbose Generic 50 mg 100 *
Acetohexamide Generic 250 mg 100 *
Chloropamide Generic 250 mg 100 *
Glimepiride Generic 2 mg 100 *
Glipizide Generic 5 mg 100 *
Glucophage Brand 500 mg 100 *
Glyburide Generic 5 mg 100 *
Insulin Brand 10 mg 100U *
Tolazamide Generic 250 mg 100 *
Tolbutamide Generic 500 mg 100 *
Troglitazone Generic 200 mg 30 *
Medications are ordered and billed pursuant to the physician's prescription. The price for each medication may vary as
manufacturers or distributors change prices. For any medication not listed above contact MediQuik for availability and pricing.
SERVICES FREQUENCY PRICE
Patient Telephone Contact 1 every 3 mos *
Educational Materials 1 every 3 mos *
Access to Information re: Classes / Seminars various *
Internet Web Site Access 24 hrs *
Nurse On Call Services - (Immediate Family Only) 24 hrs *
Pharmacist On Call Services 24 hrs *
Program Reports 1 every 3 mos *
These services are available upon the enrollment of eligible patients in The Diabetes Advantage Plan.
BILLING PROCEDURE & PRICING EXAMPLES (see The Diabetes Advantage Plan Proposal)
Products and services are grouped and shipped as one package for each patient according to their planned shipping schedule. Based
upon the physician's orders, prescriptions and the patient's profile upon enrollment, the actual content and price of each package
may vary. Typically, a three months supply of the required items is forwarded to each patient. Shipping schedules may vary,
however, based upon insulin usage and the physician's requirements.
CO-PAYMENTS, DEDUCTIBLES OR CO-INSURANCE
The price for supplies, medications and services reflect the net amount paid to MediQuik by the Payor. Co-payments, deductibles
or co-insurance are not associated with the net amount paid to MediQuik by the Payor. MediQuik has waived all co-payment
requirements.
* This information has been omitted from this exhibit and is subject to a
request for confidential treatment. In accordance with Rule 24b-2 under the
Securities Exchange Act of 1934, as amended, such information has been filed
separately with the Securities and Exchange Commission.
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