1. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com

2. 2 Experience  Over 25 million total subscribers managed  Medicaid among fastest growing class of subscribers  Program types  ASO  Full Risk Radiology Benefit Management

3. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 3 Trend, Utilization & Cost Unmanaged Medicaid vs. Managed Medicaid Trend by Modality

4. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 4 Relationship to Commercial RBM  Strategies used to manage Medicaid outpatient diagnostic imaging benefits are generally the same as those used for commercial and Medicare benefit programs  Key differences:  Frequency and site of service  Consumer knowledge and engagement  Access to care  Quality of care  Potential utilization management impact by Medicaid lines of business:  FHP – High Impact  TANF – Moderate Impact  ABAD – High Impact  CHP – Low Impact  Medicaid programs must address appropriateness and frequency of imaging with attention to under utilization

5. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 5 Strategies for Effective Radiology Benefits Management  Key  Reduction Components Impact  Prior Authorization12%  Correct Coding2% & Bundling  Steerage3%  Profiling/Reporting1%  Privileging3%

6. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 6 Nurse reviews history and findings against evidence-based criteria. If request satisfies criteria the exam is approved immediately and an authorization number is issued. If not, the case is transferred to a physician for review. Physician reviews case and as appropriate will consult with referring physician. Case is approved, non-certified or withdrawn. Physician seeks prior authorization & selects 1 of 3 portal options:  Phone  Web  Fax Physician office visit Licensed Specialist Review Physician evaluates clinical problem and chooses an imaging study Prior Authorization Overview Advanced Imaging Exams  MRI/MRA  CT  PET  Nuclear Cardiology  Nuclear Medicine Physician Review Criteria for radiology, cardiology and oncology can be found on the CareCore National’s website Proprietary Clinical Criteria

7. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 7 Assures ongoing performance monitoring. Components include professional practice/physician assessment, peer review, film review, equipment accreditation, equipment standards, specific performance-based privileging for complex imaging procedures, pay- for-performance, redirection and quality standards. Quality Assurance Professional Practice/ Provider Assessment  Practice and site details  Ownership structure  Physician information  Modalities  Equipment specifications  Policies and procedures Film Review  Randomized targeted film review to assess:  image quality  professional interpretation  Corrective actions required if deficiencies are noted Accreditation & Privileging  Proper accreditation of site and equipment  Limit the scope of imaging procedures that a physician, site or specialty will be authorized for payment when “self-referred.”

8. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 8 Network Management  Factors driving cost:  60% of all Medicaid outpatient imaging is provided at hospital outpatient departments  40% of the balance is self-referred  Need adequate access to quality free-standing imaging centers

9. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 9 Quality & Privileging  Quality considerations:  Medicaid recipients are entitled access to quality services  Equipment and performance standards are essential  Balance quality and cost  Privileging considerations  Focus on limiting self-referred imaging  Impose universal equipment and performance standards  Monitor utilization profiles

10. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 10 Experience  Over 5.5 million subscribers under management  Program types  ASO  Full Risk  Diagnostic imaging & implantable devices Cardiology Benefit Management

11. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 11 Cardiology Facts 10% 20% 30% 40% 50% 60% 0% PacemakersICD $11.8 Billion Implantable Device Cost 10% 20% 30% 40% 50% 60% 0% PacemakersICD $11.8 Billion Implantable Device Cost 10% 20% 30% 40% 50% 60% 0% PacemakersICD $11.8 Billion Implantable Device Cost 10% 20% 30% 40% 50% 60% 0% PacemakersICD $11.8 Billion Implantable Device Cost $25 Billion Imaging Costs 2% 28% 34% 8% 3% 26% Cardiac PET/MRIEchocardiography Nuclear Stress TestCoronary CT Angiography Echo Stress TestLeft Heart Catheterization ModalityTrend (yearly)Volume (2006)Cost Nuclear stress13%19 million$600-$1200 Echo stress10%3 million$300 Echocardiography8.5%26 million$350  2006 Cardiology Spending  Nuclear Medicine

12. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 12 Diagnostic Studies  Nuclear stress test  Echo stress test  Echocardiography  Cardiac PET  Cardiac MRI  Coronary CT angiography (CCTA)  Diagnostic left heart catheterization Implantable Devices  Pacemakers  Implantable cardioverter defibrillator (ICD)  Biventricular pacemakers A Comprehensive Approach Cardiology Program Components Cardiology Program Impact MODALITYApprovals /1000 Non Certs /1000 % Approved % Non-Cert % Withdrawn Cardiac Catheterization2.920.3679.7%9.77%10.53% Cardiac CT/CCTA0.060.1820.0%65.0%15.0% Cardiac MRI0.230.0353.33%6.67%40.0% Echo Stress1.861.7546.08%43.34%10.58% Echocardiography32.320.5294.99%1.54%3.48% Nuclear Stress18.604.4875.83%18.28%5.89% MEDICAID 2007

13. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 13 Oncology Benefit Management Experience  Over 24 million lives under management  ASO Program

14. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 14 MedPORTAL ™ A highly customizable, web-based medical and medication management tool, designed to meet the demands of managing injectable and specialty drug programs across all platforms  Features  Drug coverage mapping  Medical pharmacy guidelines  Online Prior Authorization  Therapeutic reimbursement management  Clinical protocol mapping  Provider education  Dose calculator  Patient drug education leaflets  Optional  Online drug and administration claims adjudication  Online medication ordering with contracted pharmacies MedPORTAL TM

15. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 15 Clinical & Utilization Overview of the BioMANAGE ™ ESA Program

16. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 16 FMV TM : Therapeutic Class Reimbursement Reimburse “lower cost alternative” at a “higher profit margin” then costlier drugs NameIndications DosagePhysician’s Physician’s Cost to Cost ProfitInsurer Zometa Hypercalcemia of malignancy 4 mg q 3-4 weeks$840.00 $84.00$924.00 ArediaHypercalcemia of malignancy 90 mg q 3-4 weeks$118.00 $11.80$129.80 Appropriate utilization management: A prior authorization is required on Zometa Proposed Physician Margin Zometa $80.00 (9.5%)$920.00 Aredia $80.00 (68%)$198.00 Savings to Insurer$722.00 Per Treatment Lower-cost Drugs Higher-cost Drugs Paid Drug Claim Prior Authorization Approved or Denied PA Required

17. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 17 RadCare TM  As an essential component of oncology treatment, radiation oncology is bringing new technology and more treatment options to members with cancer than ever before.  Recent enhancements since 2001 have represented triple digit growth in IMRT.  Future advances such as proton therapy will contribute even more to this rising cost trend. 1 CareCore Oncology, under the guidance of nationally recognized medical experts in radiation oncology have developed a series of radiation oncology pathways focusing on appropriate management and billing of radiation oncology services. 1 NY Times article, “Hospitals Look to Nuclear Tool to Fight Cancer,” Dec. 26, 2007

18. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 18 Cyber Knife $55,000 to$70,000 per Treatment The Rising Cost of Prostate Cancer Treatment

19. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 19 RadCARE TM Pathways  Pathways developed by nationally recognized radiation oncologists  RadCARE™ Pathways developed for:  Low denial rate, bundling of appropriate radiotherapy CPT codes  Reimbursement and preparation of radiopharmaceuticals  Anticipated savings between 12% to 15% Breast Cancer Prostate Cancer Bone Metastasis Brain Metastasis Lung Cancer RadCARE TM Pathways

20. © 2008 CareCore National. All rights reserved. 800-918-8924 www.carecorenational.com 20 LabMANAGE ™ With the movement towards individualized medicine in its infancy, the current and forthcoming lab studies in:  Genetics  Genomics  Cytopathology  Cytogentics  Pharmacogenomics  Chemogenomics necessitates the appropriate identification and management of these costly tests New Lab Testing Technology Direct to Consumer Advertising Rising Lab Utilization & Cost In conjunction with the University of Washington, Dept. of Laboratory Medicine, CareCore National has produced: 1.Evidenced-based lab study review criteria 2.Diagnosis appropriate lab study guidelines 3.Treatment-specific lab management tools This process identifies appropriate studies resulting in improved treatment outcomes while reducing the cost associated to unnecessary and/or inappropriate lab studies.