*12575201820100100* HEALTH ANNUAL STATEMENT FOR THE YEAR ENDED DECEMBER 31, 2018 OF THE CONDITION AND AFFAIRS OF THE SilverScript Insurance Company NAIC Group Code 0001 4667 (Current) (Prior) Organized under the Laws of NAIC Company Code Tennessee 12575 Employer's ID Number , State of Domicile or Port of Entry Country of Domicile 20-2833904 TN United States of America Licensed as business type: Life, Accident & Health Is HMO Federally Qualified? Yes [ ] No [ X ] Incorporated/Organized 05/11/2005 Statutory Home Office Commenced Business 445 Great Circle Road (Street and Number) , Main Administrative Office Mail Address Nashville, TN, US 37228 (City or Town, State, Country and Zip Code) 445 Great Circle Road (Street and Number) , Nashville, TN, US 37228 (City or Town, State, Country and Zip Code) 445 Great Circle Road (Street and Number or P.O. Box) , Primary Location of Books and Records 615-743-6600 (Area Code) (Telephone Number) Nashville, TN, US 37228 (City or Town, State, Country and Zip Code) 445 Great Circle Road (Street and Number) , Nashville, TN, US 37228 (City or Town, State, Country and Zip Code) Internet Website Address 01/01/2006 615-743-6600 (Area Code) (Telephone Number) www.silverscript.com Statutory Statement Contact Xiaoqi Glenn Wang (Name) Xiaoqi.Wang@CVSCaremark.com (E-mail Address) , 401-770-9669 (Area Code) (Telephone Number) 401-733-0136 (FAX Number) , OFFICERS President Todd Dean Meek Treasurer Daniel Lee Zablocki Secretary Actuary Michele Wugalter Buchanan Rebecca Conway Justice OTHER DIRECTORS OR TRUSTEES Harold Neil Lund Mary Kristina Meyer State of County of Todd Dean Meek David Scott Azzolina Marsha Carolyn Moore SS: The officers of this reporting entity being duly sworn, each depose and say that they are the described officers of said reporting entity, and that on the reporting period stated above, all of the herein described assets were the absolute property of the said reporting entity, free and clear from any liens or claims thereon, except as herein stated, and that this statement, together with related exhibits, schedules and explanations therein contained, annexed or referred to, is a full and true statement of all the assets and liabilities and of the condition and affairs of the said reporting entity as of the reporting period stated above, and of its income and deductions therefrom for the period ended, and have been completed in accordance with the NAIC Annual Statement Instructions and Accounting Practices and Procedures manual except to the extent that: (1) state law may differ; or, (2) that state rules or regulations require differences in reporting not related to accounting practices and procedures, according to the best of their information, knowledge and belief, respectively. Furthermore, the scope of this attestation by the described officers also includes the related corresponding electronic filing with the NAIC, when required, that is an exact copy (except for formatting differences due to electronic filing) of the enclosed statement. The electronic filing may be requested by various regulators in lieu of or in addition to the enclosed statement. Todd Dean Meek President Subscribed and sworn to before me this day of Michele Wugalter Buchanan Secretary a. Is this an original filing? b. If no, 1. State the amendment number 2. Date filed 3. Number of pages attached Daniel Lee Zablocki Treasurer Yes [ X ] No [ ] *12575201821000100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company ACCIDENT AND HEALTH POLICY EXPERIENCE EXHIBIT FOR YEAR NAIC Group Code 0001 210-1 A. INDIVIDUAL BUSINESS 1. Comprehensive Major Medical 1.1 With Contract Reserves 1.2 Without Contract Reserves 1.3 Subtotal 2. Short-Term Medical 2.1 With Contract Reserves 2.2 Without Contract Reserves 2.3 Subtotal 3. Other Medical (Non-Comprehensive) 3.1 With Contract Reserves 3.2 Without Contract Reserves 3.3 Subtotal 4. Specified/Named Disease 4.1 With Contract Reserves 4.2 Without Contract Reserves 4.3 Subtotal 5. Limited Benefit 5.1 With Contract Reserves 5.2 Without Contract Reserves 5.3 Subtotal 6. Student 6.1 With Contract Reserves 6.2 Without Contract Reserves 6.3 Subtotal 7. Accident Only or AD&D 7.1 With Contract Reserves 7.2 Without Contract Reserves 7.3 Subtotal 8. Disability Income - Short - Term 8.1 With Contract Reserves 8.2 Without Contract Reserves 8.3 Subtotal United States Policy Forms Direct Business Only For The Year Ended December 31, 2018 (To Be Filed By April 1) 1 2 3 4 Premiums Earned Incurred Claims Amount Change in Contract Reserves Loss Ratio (2+3)/1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 Number of Policies or Certificates as of Dec. 31 NAIC Company Code 12575 6 7 Number of Covered Lives as of Dec. 31 Member Months 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company ACCIDENT AND HEALTH POLICY EXPERIENCE EXHIBIT FOR YEAR 210-2 A. INDIVIDUAL BUSINESS (Continued) 9. Disability Income - Long - Term 9.1 With Contract Reserves 9.2 Without Contract Reserves 9.3 Subtotal 10. Long-Term Care 10.1 With Contract Reserves 10.2 Without Contract Reserves 10.3 Subtotal 11. Medicare Supplement (Medigap) 11.1 With Contract Reserves 11.2 Without Contract Reserves 11.3 Subtotal 12. Dental 12.1 With Contract Reserves 12.2 Without Contract Reserves 12.3 Subtotal 13. State Children’s Health Insurance Program 13.1 With Contract Reserves 13.2 Without Contract Reserves 13.3 Subtotal 14. Medicare 14.1 With Contract Reserves 14.2 Without Contract Reserves 14.3 Subtotal 15. Medicaid 15.1 With Contract Reserves 15.2 Without Contract Reserves 15.3 Subtotal 16. Medicare Part D - Stand-Alone 16.1 With Contract Reserves 16.2 Without Contract Reserves 16.3 Subtotal 17. Other Individual Business 17.1 With Contract Reserves 17.2 Without Contract Reserves 17.3 Subtotal 18. Total Individual Business 18.1 With Contract Reserves 18.2 Without Contract Reserves 19. Grand Total Individual 1 2 3 4 Premiums Earned Incurred Claims Amount Change in Contract Reserves Loss Ratio (2+3)/1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,342,570,900 3,342,570,900 2,779,166,734 2,779,166,734 5 Number of Policies or Certificates as of Dec. 31 6 Number of Covered Lives as of Dec. 31 7 Member Months 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 0.0 0.0 0 0 0 0 0.0 83.1 83.1 4,859,001 4,859,001 4,859,001 4,859,001 57,971,729 57,971,729 0 0 0 0 4,859,001 4,859,001 0 4,859,001 4,859,001 0 57,971,729 57,971,729 0 0 0 0.0 0.0 0.0 0 3,342,570,900 3,342,570,900 0 2,779,166,734 2,779,166,734 0 0 0 0.0 83.1 83.1 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company ACCIDENT AND HEALTH POLICY EXPERIENCE EXHIBIT FOR YEAR 210-3 B. GROUP BUSINESS Comprehensive Major Medical 1. Single Employer 1.1 Small Employer 1.2 Other Employer 1.3 Single Employer Subtotal 2. Multiple Employer Assns and Trusts 3. Other Associations and Discretionary Trusts 4. Other Comprehensive Major Medical 5. Comprehensive/Major Medical Subtotal Other Medical (Non-Comprehensive) 6. Specified/Named Disease 7. Limited Benefit 8. Student 9. Accident Only or AD&D 10. Disability Income - Short-term 11. Disability Income - Long-term 12. Long-Term Care 13. Medicare Supplement (Medigap) 14. Federal Employees Health Benefits Plans 15. Tricare 16. Dental 17. Medicare 18. Medicare Part D - Stand-Alone 19. Other Group Care 20. Grand Total Group Business C. OTHER BUSINESS 1. Credit (Individual and Group) 2. Stop Loss/Excess Loss 3. Administrative Services Only 4. Administrative Services Contracts 5. Grand Total Other Business D. TOTAL BUSINESS 1. Total Non U.S. Policy Forms 2. Grand Total Individual, Group and Other Business 1 2 3 4 Premiums Earned Incurred Claims Amount Change in Contract Reserves Loss Ratio (2+3)/1 5 Number of Policies or Certificates as of Dec. 31 0 0 0 0 0 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 94.0 0.0 94.0 27,714,175 26,049,251 27,714,175 26,049,251 6 Number of Covered Lives as of Dec. 31 7 Member Months 0 0 0 0 0 0 9,344 9,344 119,085 9,344 9,344 119,085 0.0 0.0 XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 0.0 1,308,011 1,308,011 1,308,011 1,308,011 15,213,696 15,213,696 3,370,285,075 2,805,215,985 0 0.0 83.2 6,176,356 6,176,356 73,304,510 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company ACCIDENT AND HEALTH POLICY EXPERIENCE EXHIBIT FOR YEAR PART 1 – INDIVIDUAL POLICIES SUMMARY 1 Description 1. 2. 3. 4. 5. 6. Premiums Earned U.S. Forms Direct Business Other Forms Direct Business Total Direct Business Reinsurance Assumed Less Reinsurance Ceded Total 2 Incurred Claims Amount 3,342,570,900 2,779,166,734 3,342,570,900 (102,714) 671,803,024 2,670,665,162 2,779,166,734 (184,222) 546,343,670 2,232,638,842 3 Change in Contract Reserves 0 0 4 Loss Ratio (2+3)/1 83.1 0.0 83.1 179.4 81.3 83.6 PART 2 – GROUP POLICIES SUMMARY 1 Description 1. 2. 3. 4. 5. 6. Premiums Earned U.S. Forms Direct Business Other Forms Direct Business Total Direct Business Reinsurance Assumed Less Reinsurance Ceded Total 2 Incurred Claims Amount 27,714,175 26,049,251 27,714,175 0 5,267,127 22,447,048 26,049,251 0 5,302,320 20,746,931 3 Change in Contract Reserves 0 0 4 Loss Ratio (2+3)/1 94.0 0.0 94.0 0.0 100.7 92.4 210-4 PART 3 – CREDIT POLICIES (Individual and Group) SUMMARY 1 Description 1. 2. 3. 4. 5. 6. U.S. Forms Direct Business Other Forms Direct Business Total Direct Business Reinsurance Assumed Less Reinsurance Ceded Total NONE Premiums Earned 2 Incurred Claims Amount 3 Change in Contract Reserves 4 Loss Ratio (2+3)/1 2 Incurred Claims Amount 3 Change in Contract Reserves 4 Loss Ratio (2+3)/1 PART 4 – ALL INDIVIDUAL, GROUP AND CREDIT POLICIES SUMMARY 1 Description 1. 2. 3. 4. 5. 6. U.S. Forms Direct Business Other Forms Direct Business Total Direct Business Reinsurance Assumed Less Reinsurance Ceded Total Premiums Earned 3,370,285,075 0 3,370,285,075 (102,714) 677,070,151 2,693,112,210 2,805,215,985 0 2,805,215,985 (184,222) 551,645,990 2,253,385,773 0 0 0 0 0 0 83.2 0.0 83.2 179.4 81.5 83.7 *12575201821601100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Alabama DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.AL 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 53,921,172 53,921,172 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53,921,172 2,192,713 53,921,172 2,192,713 XXX 0 0 0 0 0 0 0 0 0 0 0 48,767 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9,540 51,670,152 (10,907,003) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43,332,689 (8,597,777) 0 0 34,734,912 0 0 405,685 405,685 0 0 0 0 145,948 551,633 0 0 0 0 0 405,685 0.846 405,685 XXX 145,948 XXX 551,633 XXX 0 0 0.000 904,835 904,835 0.018 0 904,835 904,835 XXX 350,280 350,280 XXX 0 1,255,115 1,255,115 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 40,763,149 XXX XXX XXX XXX XXX 48,767 0 9,540 51,670,152 (10,907,003) 0 0 40,763,149 (376,390) 98,185,197 54,479,388 (376,390) 98,185,197 54,479,388 XXX XXX XXX (376,390) 98,185,197 54,479,388 0 3,270 0 43,332,689 (8,597,777) 0 0 0 0 0 34,734,912 XXX XXX 0 3,270 0 43,332,689 (8,597,777) 0 0 0 0 0 34,734,912 3,270 0 53,921,172 2,192,713 48,767 0 9,540 51,670,152 (10,907,003) 0 0 40,763,149 XXX XXX XXX XXX 53,921,172 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 402 1,333,260 402 1,333,260 0 0 0 0 0 0 0 0 0 0 0 2,887,275 0 0 0 0 0 0 0 0 0 0 0 4,220,937 0 2,887,275 0 4,220,937 0 0 0 0 0 0 0 0 0 0 0 496,780 496,780 0 1,221,906 1,221,906 0 4,109,181 0 5,442,843 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 402 1,333,260 (1,221,354) 1,781,136 216,319 713,099 XXX 1,781,136 216,319 XXX 0 XXX 776,101 OTHER INDICATORS: 216-2.AL 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 78,418 78,418 8,180 86,598 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 78,418 78,418 8,180 86,598 3. Number of Groups 4. Member Months 98,025 1,041,895 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 943,870 943,870 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Alabama DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.AL Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 53,949,750 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,260 123,177 511,827 (388,650) 28,578 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53,921,172 (899) (10,907,003) (899) 0 0 0 0 0 0 0 0 0 0 43,390,559 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 41,556,030 131,839 92,982 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,260 123,177 511,827 3,270 14,600 779 12,109 (2,110,919) 8,148,900 10,259,819 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43,332,686 (3,959) (8,597,777) (3,959) 0 0 0 0 0 0 0 0 0 0 35,111,299 53,949,750 0 0 0 12,260 123,177 511,827 (388,650) 28,578 0 53,921,172 (899) (10,907,003) (899) 0 43,390,559 41,556,030 131,839 92,982 0 0 0 0 12,260 123,177 511,827 3,270 14,600 779 12,109 (2,110,919) 8,148,900 10,259,819 0 0 43,332,686 (3,959) (8,597,777) (3,959) 0 35,111,299 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Alabama DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.AL Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.AL 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.AL 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821602100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Alaska DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.AK 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 1,181,481 1,181,481 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,181,481 118,191 1,181,481 118,191 XXX 0 0 0 0 0 0 0 0 0 0 0 1,069 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 209 1,062,012 (239,040) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 805,417 (160,422) 0 0 644,995 0 0 8,889 0 8,889 0.767 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 0 0.000 0 822,972 XXX XXX XXX XXX XXX 1,069 0 209 1,062,012 (239,040) 0 0 822,972 (10,130) 1,831,991 1,016,505 (10,130) 1,831,991 1,016,505 XXX XXX XXX (10,130) 1,831,991 1,016,505 0 61 0 805,417 (160,422) 0 0 0 0 0 644,995 XXX XXX 0 61 0 805,417 (160,422) 0 0 0 0 0 644,995 61 19,826 19,826 0.019 0 1,181,481 118,191 1,069 0 209 1,062,012 (239,040) 0 0 822,972 XXX XXX XXX XXX 1,181,481 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX 8,889 0 0 0 0 8,889 XXX 0 19,826 19,826 XXX 3,198 12,087 0 0 0 0 3,198 12,087 XXX XXX 7,675 7,675 XXX 0 27,501 27,501 XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 29,213 9 29,213 0 0 0 0 0 0 0 0 0 0 0 63,264 0 0 0 0 0 0 0 0 0 0 0 92,486 0 63,264 0 92,486 0 0 0 0 0 0 0 0 0 0 0 56,776 56,776 0 26,774 26,774 0 90,038 0 119,260 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 9 29,213 19,129 39,027 5,969 62,745 XXX 39,027 5,969 XXX 0 XXX 64,125 OTHER INDICATORS: 216-2.AK 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 1,069 1,069 192 1,261 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 1,069 1,069 192 1,261 3. Number of Groups 4. Member Months 2,378 15,438 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 13,060 13,060 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Alaska DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.AK Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 1,182,107 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (239,040) 0 0 0 0 0 0 0 0 0 0 952,571 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 743,272 2,459 2,027 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,700 12,830 61 312 15 266 (71,782) 152,047 223,829 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 805,417 (116) (160,422) (116) 0 0 0 0 0 0 0 0 0 0 655,125 2,700 12,830 (10,130) 626 1,181,481 1,182,107 0 0 0 0 2,700 12,830 (10,130) 626 0 1,181,481 0 (239,040) 0 0 952,571 743,272 2,459 2,027 0 0 0 0 0 2,700 12,830 61 312 15 266 (71,782) 152,047 223,829 0 0 805,417 (116) (160,422) (116) 0 655,125 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Alaska DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.AK Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.AK 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.AK 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821603100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Arizona DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.AZ 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 35,012,823 35,012,823 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35,012,823 3,566,825 35,012,823 3,566,825 XXX 0 0 0 0 0 0 0 0 0 0 0 31,665 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6,194 31,408,139 (7,091,987) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 25,217,779 (5,020,283) 0 0 20,197,496 0 0 263,426 263,426 0 0 0 0 94,770 358,196 0 0 0 0 0 263,426 0.811 263,426 XXX 94,770 XXX 358,196 XXX 0 0 0.000 587,539 587,539 0.019 0 587,539 587,539 XXX 227,449 227,449 XXX 0 814,988 814,988 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 24,316,152 XXX XXX XXX XXX XXX 31,665 0 6,194 31,408,139 (7,091,987) 0 0 24,316,152 (304,160) 57,330,801 31,810,772 (304,160) 57,330,801 31,810,772 XXX XXX XXX (304,160) 57,330,801 31,810,772 0 1,910 0 25,217,779 (5,020,283) 0 0 0 0 0 20,197,496 XXX XXX 0 1,910 0 25,217,779 (5,020,283) 0 0 0 0 0 20,197,496 1,910 0 35,012,823 3,566,825 31,665 0 6,194 31,408,139 (7,091,987) 0 0 24,316,152 XXX XXX XXX XXX 35,012,823 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 262 865,728 262 865,728 0 0 0 0 0 0 0 0 0 0 0 1,874,805 0 0 0 0 0 0 0 0 0 0 0 2,740,795 0 1,874,805 0 2,740,795 0 0 0 0 0 0 0 0 0 0 0 526,896 526,896 0 793,425 793,425 0 2,668,230 0 3,534,220 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 262 865,728 (588,748) 1,156,553 1,375,696 1,902,592 XXX 1,156,553 1,375,696 XXX 0 XXX 1,943,501 OTHER INDICATORS: 216-2.AZ 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 58,453 58,453 13,348 71,801 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 58,453 58,453 13,348 71,801 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 698,609 158,821 857,430 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 698,609 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Arizona DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.AZ Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 35,031,403 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (40,018) 80,094 344,236 (264,142) 18,580 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35,012,823 (1,764) (7,091,987) (1,764) 0 0 0 0 0 0 0 0 0 0 28,224,996 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24,368,906 76,982 53,341 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (40,018) 80,094 344,236 1,910 8,401 455 6,946 (1,127,482) 4,758,183 5,885,665 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 25,217,779 (2,572) (5,020,283) (2,572) 0 0 0 0 0 0 0 0 0 0 20,501,656 35,031,403 0 0 0 (40,018) 80,094 344,236 (264,142) 18,580 0 35,012,823 (1,764) (7,091,987) (1,764) 0 28,224,996 24,368,906 76,982 53,341 0 0 0 0 (40,018) 80,094 344,236 1,910 8,401 455 6,946 (1,127,482) 4,758,183 5,885,665 0 0 25,217,779 (2,572) (5,020,283) (2,572) 0 20,501,656 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Arizona DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.AZ Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.AZ 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.AZ 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821604100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Arkansas DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.AR 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 49,812,804 49,812,804 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 49,812,804 711,138 49,812,804 711,138 XXX 0 0 0 0 0 0 0 0 0 0 0 45,050 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8,813 49,047,803 (11,087,582) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42,717,531 (9,448,369) 0 0 33,269,162 0 0 374,797 374,797 0 0 0 0 134,830 509,627 0 0 0 0 0 374,797 0.879 374,797 XXX 134,830 XXX 509,627 XXX 0 0 0.000 835,937 835,937 0.017 0 835,937 835,937 XXX 323,592 323,592 XXX 0 1,159,529 1,159,529 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 37,960,221 XXX XXX XXX XXX XXX 45,050 0 8,813 49,047,803 (11,087,582) 0 0 37,960,221 (5,315,756) 107,898,811 59,869,118 (5,315,756) 107,898,811 59,869,118 XXX XXX XXX (5,315,756) 107,898,811 59,869,118 0 3,594 0 42,717,531 (9,448,369) 0 0 0 0 0 33,269,162 XXX XXX 0 3,594 0 42,717,531 (9,448,369) 0 0 0 0 0 33,269,162 3,594 0 49,812,804 711,138 45,050 0 8,813 49,047,803 (11,087,582) 0 0 37,960,221 XXX XXX XXX XXX 49,812,804 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 372 1,231,737 0 0 0 0 0 0 0 0 0 0 0 2,667,428 0 0 0 0 0 0 0 0 0 0 0 3,899,537 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 372 1,231,737 0 2,667,428 0 3,899,537 0 1,128,808 1,128,808 0 3,796,236 0 5,028,345 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (419,212) (419,212) XXX XXX 372 1,231,737 (2,006,442) 1,645,432 194,969 XXX 194,969 XXX (224,243) 1,645,432 0 XXX (166,041) OTHER INDICATORS: 216-2.AR 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 102,139 102,139 3,583 105,722 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 102,139 102,139 3,583 105,722 3. Number of Groups 4. Member Months 43,755 1,249,998 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 1,206,243 1,206,243 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Arkansas DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.AR Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 49,841,852 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (4,988,658) 125,218 452,316 (327,098) 29,048 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 49,812,804 (1,261) (11,087,582) (1,261) 0 0 0 0 0 0 0 0 0 0 44,040,978 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 46,768,225 144,883 92,114 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (4,988,658) 125,218 452,316 3,594 14,731 856 11,993 (1,208,699) 8,955,086 10,163,785 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42,717,531 (3,244) (9,448,369) (3,244) 0 0 0 0 0 0 0 0 0 0 38,584,918 49,841,852 0 0 0 (4,988,658) 125,218 452,316 (327,098) 29,048 0 49,812,804 (1,261) (11,087,582) (1,261) 0 44,040,978 46,768,225 144,883 92,114 0 0 0 0 (4,988,658) 125,218 452,316 3,594 14,731 856 11,993 (1,208,699) 8,955,086 10,163,785 0 0 42,717,531 (3,244) (9,448,369) (3,244) 0 38,584,918 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Arkansas DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.AR Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.AR 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.AR 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821605100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF California DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.CA 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 375,615,873 375,615,873 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 375,615,873 6,044,025 375,615,873 6,044,025 XXX 0 0 0 0 0 0 0 0 0 0 0 339,704 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 66,453 369,165,691 (76,191,081) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 320,876,739 (63,758,054) 0 0 257,118,685 0 0 2,826,026 2,826,026 0 0 0 0 1,016,691 3,842,717 0 0 0 0 0 2,826,026 0.877 2,826,026 XXX 1,016,691 XXX 3,842,717 XXX 0 0 0.000 6,303,095 6,303,095 0.017 0 6,303,095 6,303,095 XXX 2,440,058 2,440,058 XXX 0 8,743,153 8,743,153 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 292,974,610 XXX XXX XXX XXX XXX 339,704 0 66,453 369,165,691 (76,191,081) 0 0 292,974,610 (3,254,218) 728,106,427 403,999,721 (3,254,218) 728,106,427 403,999,721 XXX XXX XXX (3,254,218) 728,106,427 403,999,721 0 24,251 0 320,876,739 (63,758,054) 0 0 0 0 0 257,118,685 XXX XXX 0 24,251 0 320,876,739 (63,758,054) 0 0 0 0 0 257,118,685 24,251 0 375,615,873 6,044,025 339,704 0 66,453 369,165,691 (76,191,081) 0 0 292,974,610 XXX XXX XXX XXX 375,615,873 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,806 9,287,494 2,806 9,287,494 0 0 0 0 0 0 0 0 0 0 0 20,112,835 0 0 0 0 0 0 0 0 0 0 0 29,403,135 0 20,112,835 0 29,403,135 0 0 0 0 0 0 0 0 0 0 0 (2,676,331) (2,676,331) XXX XXX 12,407,451 0 8,511,830 8,511,830 2,806 9,287,494 0 28,624,665 0 37,914,965 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 1,443,308 (14,644,910) XXX 1,443,308 XXX (1,233,023) 12,407,451 0 XXX (794,151) OTHER INDICATORS: 216-2.CA 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 521,282 521,282 51,665 572,947 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 521,282 521,282 51,665 572,947 3. Number of Groups 0 0 0 0 0 0 0 0 0 1 1 3 4 4. Member Months 0 0 0 0 0 0 0 0 0 6,217,915 6,217,915 627,253 6,845,168 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 California DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.CA Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 375,815,485 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (966,021) 860,468 3,148,665 (2,288,197) 199,612 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 375,615,873 (11,102) (76,191,081) (11,102) 0 0 0 0 0 0 0 0 0 0 302,679,010 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 309,012,325 977,677 681,768 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (966,021) 860,468 3,148,665 24,251 107,261 5,777 88,787 (14,798,475) 60,429,360 75,227,835 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 320,876,742 (17,446) (63,758,054) (17,446) 0 0 0 0 0 0 0 0 0 0 260,372,906 375,815,485 0 0 0 (966,021) 860,468 3,148,665 (2,288,197) 199,612 0 375,615,873 (11,102) (76,191,081) (11,102) 0 302,679,010 309,012,325 977,677 681,768 0 0 0 0 (966,021) 860,468 3,148,665 24,251 107,261 5,777 88,787 (14,798,475) 60,429,360 75,227,835 0 0 320,876,742 (17,446) (63,758,054) (17,446) 0 260,372,906 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF California DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.CA Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.CA 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.CA 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821606100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Colorado DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.CO 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 27,083,749 27,083,749 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27,083,749 1,431,978 27,083,749 1,431,978 XXX 0 0 0 0 0 0 0 0 0 0 0 24,494 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,792 25,622,485 (5,483,311) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21,077,314 (4,179,701) 0 0 16,897,613 0 0 203,770 203,770 0 0 0 0 73,308 277,078 0 0 0 0 0 203,770 0.831 203,770 XXX 73,308 XXX 277,078 XXX 0 0 0.000 454,484 454,484 0.018 0 454,484 454,484 XXX 175,940 175,940 XXX 0 630,424 630,424 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 20,139,174 XXX XXX XXX XXX XXX 24,494 0 4,792 25,622,485 (5,483,311) 0 0 20,139,174 (171,303) 47,731,493 26,484,466 (171,303) 47,731,493 26,484,466 XXX XXX XXX (171,303) 47,731,493 26,484,466 0 1,590 0 21,077,314 (4,179,701) 0 0 0 0 0 16,897,613 XXX XXX 0 1,590 0 21,077,314 (4,179,701) 0 0 0 0 0 16,897,613 1,590 0 27,083,749 1,431,978 24,494 0 4,792 25,622,485 (5,483,311) 0 0 20,139,174 XXX XXX XXX XXX 27,083,749 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 202 669,673 202 669,673 0 0 0 0 0 0 0 0 0 0 0 1,450,233 0 0 0 0 0 0 0 0 0 0 0 2,120,108 0 1,450,233 0 2,120,108 0 0 0 0 0 0 0 0 0 0 0 463,199 463,199 0 613,745 613,745 0 2,063,978 0 2,733,853 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 202 669,673 (399,794) 894,638 117,064 580,263 XXX 894,638 117,064 XXX 0 XXX 611,908 OTHER INDICATORS: 216-2.CO 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 41,702 41,702 32,841 74,543 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 41,702 41,702 32,841 74,543 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 2 2 4. Member Months 0 0 0 0 0 0 0 0 0 485,477 389,626 875,103 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 485,477 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Colorado DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.CO Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 27,098,115 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (18,053) 61,926 215,176 (153,250) 14,366 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27,083,749 (207) (5,483,311) (207) 0 0 0 0 0 0 0 0 0 0 21,771,741 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20,799,151 64,092 39,743 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (18,053) 61,926 215,176 1,590 6,384 379 5,173 (423,527) 3,961,486 4,385,013 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21,077,314 (1,351) (4,179,701) (1,351) 0 0 0 0 0 0 0 0 0 0 17,068,916 27,098,115 0 0 0 (18,053) 61,926 215,176 (153,250) 14,366 0 27,083,749 (207) (5,483,311) (207) 0 21,771,741 20,799,151 64,092 39,743 0 0 0 0 (18,053) 61,926 215,176 1,590 6,384 379 5,173 (423,527) 3,961,486 4,385,013 0 0 21,077,314 (1,351) (4,179,701) (1,351) 0 17,068,916 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Colorado DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.CO Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.CO 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.CO 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821607100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Connecticut DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.CT 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 43,175,223 43,175,223 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43,175,223 1,003,811 43,175,223 1,003,811 XXX 0 0 0 0 0 0 0 0 0 0 0 39,047 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,638 42,124,727 (8,735,596) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 36,259,006 (7,193,116) 0 0 29,065,890 0 0 324,838 324,838 0 0 0 0 116,864 441,702 0 0 0 0 0 324,838 0.868 324,838 XXX 116,864 XXX 441,702 XXX 0 0 0.000 724,509 724,509 0.017 0 724,509 724,509 XXX 280,473 280,473 XXX 0 1,004,982 1,004,982 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 33,389,131 XXX XXX XXX XXX XXX 39,047 0 7,638 42,124,727 (8,735,596) 0 0 33,389,131 (309,104) 82,144,193 45,578,819 (309,104) 82,144,193 45,578,819 XXX XXX XXX (309,104) 82,144,193 45,578,819 0 2,736 0 36,259,006 (7,193,116) 0 0 0 0 0 29,065,890 XXX XXX 0 2,736 0 36,259,006 (7,193,116) 0 0 0 0 0 29,065,890 2,736 0 43,175,223 1,003,811 39,047 0 7,638 42,124,727 (8,735,596) 0 0 33,389,131 XXX XXX XXX XXX 43,175,223 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 323 1,067,551 0 0 0 0 0 0 0 0 0 0 0 2,311,870 0 0 0 0 0 0 0 0 0 0 0 3,379,744 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 323 1,067,551 0 2,311,870 0 3,379,744 0 978,394 978,394 0 3,290,264 0 4,358,138 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (105,850) (105,850) XXX XXX 323 1,067,551 (1,481,581) 1,426,177 171,740 65,890 XXX 1,426,177 171,740 XXX 0 XXX 116,336 OTHER INDICATORS: 216-2.CT 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 53,942 53,942 9,431 63,373 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 53,942 53,942 9,431 63,373 3. Number of Groups 0 0 0 0 0 0 0 0 0 2 2 3 5 4. Member Months 0 0 0 0 0 0 0 0 0 652,688 652,688 116,159 768,847 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Connecticut DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.CT Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 43,198,109 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (1,316) 98,656 406,444 (307,788) 22,886 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43,175,223 (1,242) (8,735,596) (1,242) 0 0 0 0 0 0 0 0 0 0 34,748,731 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 34,434,485 110,300 80,830 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (1,316) 98,656 406,444 2,736 12,611 652 10,527 (2,101,419) 6,817,576 8,918,995 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 36,259,006 (2,806) (7,193,116) (2,806) 0 0 0 0 0 0 0 0 0 0 29,374,994 43,198,109 0 0 0 (1,316) 98,656 406,444 (307,788) 22,886 0 43,175,223 (1,242) (8,735,596) (1,242) 0 34,748,731 34,434,485 110,300 80,830 0 0 0 0 (1,316) 98,656 406,444 2,736 12,611 652 10,527 (2,101,419) 6,817,576 8,918,995 0 0 36,259,006 (2,806) (7,193,116) (2,806) 0 29,374,994 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Connecticut DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.CT Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.CT 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.CT 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821608100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Delaware DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.DE 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 10,316,916 10,316,916 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,316,916 595,834 10,316,916 595,834 XXX 0 0 0 0 0 0 0 0 0 0 0 9,331 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,825 9,709,926 (2,043,243) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 7,666,683 XXX XXX XXX XXX XXX 9,331 0 1,825 9,709,926 (2,043,243) 0 0 7,666,683 0 0 0 155,954 17,445,154 9,679,680 155,954 17,445,154 9,679,680 XXX XXX XXX 155,954 17,445,154 9,679,680 0 0 581 XXX XXX 0 0 0 0 7,922,009 (1,527,619) 0 0 6,394,390 0 581 0 7,922,009 (1,527,619) 0 0 0 0 0 6,394,390 0 581 0 7,922,009 (1,527,619) 0 0 0 0 0 6,394,390 0 0 77,621 77,621 0 0 0 0 27,925 105,546 0 0 0 0 0 77,621 0.824 77,621 XXX 27,925 XXX 105,546 XXX 0 0 0.000 173,123 173,123 0.018 0 173,123 173,123 XXX 67,020 67,020 XXX 0 240,143 240,143 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 10,316,916 595,834 9,331 0 1,825 9,709,926 (2,043,243) 0 0 7,666,683 XXX XXX XXX 0 10,316,916 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 77 255,093 77 255,093 0 0 0 0 0 0 0 0 0 0 0 552,426 0 0 0 0 0 0 0 0 0 0 0 807,596 0 552,426 0 807,596 0 0 0 0 0 0 0 0 0 0 0 213,953 213,953 0 233,792 233,792 0 786,218 0 1,041,388 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 77 255,093 (114,784) 340,791 40,910 254,863 XXX 340,791 40,910 XXX 0 XXX 266,917 OTHER INDICATORS: 216-2.DE 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 14,427 14,427 4,826 19,253 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 14,427 14,427 4,826 19,253 3. Number of Groups 4. Member Months 55,532 224,968 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 169,436 169,436 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Delaware DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.DE Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 10,322,269 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 217,988 23,075 85,109 (62,034) 5,353 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,316,916 (119) (2,043,243) (119) 0 0 0 0 0 0 0 0 0 0 8,117,719 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,447,637 23,425 15,935 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 217,988 23,075 85,109 581 2,517 138 2,074 (310,347) 1,447,865 1,758,212 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,922,009 (1,015) (1,527,619) (1,015) 0 0 0 0 0 0 0 0 0 0 6,238,436 10,322,269 0 0 0 217,988 23,075 85,109 (62,034) 5,353 0 10,316,916 (119) (2,043,243) (119) 0 8,117,719 7,447,637 23,425 15,935 0 0 0 0 217,988 23,075 85,109 581 2,517 138 2,074 (310,347) 1,447,865 1,758,212 0 0 7,922,009 (1,015) (1,527,619) (1,015) 0 6,238,436 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Delaware DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.DE Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.DE 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.DE 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821609100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF District of Columbia DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.DC 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 5,586,696 5,586,696 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,586,696 388,090 5,586,696 388,090 XXX 0 0 0 0 0 0 0 0 0 0 0 5,053 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 988 5,192,565 (1,104,139) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 4,088,426 XXX XXX XXX XXX XXX 5,053 0 988 5,192,565 (1,104,139) 0 0 4,088,426 0 0 0 92,747 9,126,220 5,063,807 92,747 9,126,220 5,063,807 XXX XXX XXX 92,747 9,126,220 5,063,807 0 0 304 XXX XXX 0 0 0 0 4,155,464 (799,155) 0 0 3,356,309 0 304 0 4,155,464 (799,155) 0 0 0 0 0 3,356,309 0 304 0 4,155,464 (799,155) 0 0 0 0 0 3,356,309 0 0 42,032 42,032 0 0 0 0 15,122 57,154 0 0 0 0 0 42,032 0.808 42,032 XXX 15,122 XXX 57,154 XXX 0 0 0.000 93,747 93,747 0.018 0 93,747 93,747 XXX 36,292 36,292 XXX 0 130,039 130,039 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 5,586,696 388,090 5,053 0 988 5,192,565 (1,104,139) 0 0 4,088,426 XXX XXX XXX 0 5,586,696 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42 138,135 42 138,135 0 0 0 0 0 0 0 0 0 0 0 299,143 0 0 0 0 0 0 0 0 0 0 0 437,320 0 299,143 0 437,320 0 0 0 0 0 0 0 0 0 0 0 159,018 159,018 0 126,600 126,600 0 425,743 0 563,920 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 42 138,135 (18,996) 184,542 22,951 181,969 XXX 184,542 22,951 XXX 0 XXX 188,497 OTHER INDICATORS: 216-2.DC 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 6,275 6,275 1,645 7,920 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 6,275 6,275 1,645 7,920 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 2 2 4. Member Months 0 0 0 0 0 0 0 0 0 75,209 19,299 94,508 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 75,209 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 District of Columbia DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.DC Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 5,589,589 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 129,379 12,470 49,102 (36,632) 2,893 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,586,696 (236) (1,104,139) (236) 0 0 0 0 0 0 0 0 0 0 4,389,810 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,823,715 12,255 9,000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 129,379 12,470 49,102 304 1,402 72 1,170 (235,443) 757,433 992,876 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,155,464 (456) (799,155) (456) 0 0 0 0 0 0 0 0 0 0 3,263,562 5,589,589 0 0 0 129,379 12,470 49,102 (36,632) 2,893 0 5,586,696 (236) (1,104,139) (236) 0 4,389,810 3,823,715 12,255 9,000 0 0 0 0 129,379 12,470 49,102 304 1,402 72 1,170 (235,443) 757,433 992,876 0 0 4,155,464 (456) (799,155) (456) 0 3,263,562 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF District of Columbia DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.DC Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.DC 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.DC 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821610100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Florida DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.FL 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 314,110,854 314,110,854 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 314,110,854 27,500,339 314,110,854 27,500,339 XXX 0 0 0 0 0 0 0 0 0 0 0 284,079 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 55,572 286,270,864 (63,183,179) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 223,087,685 XXX XXX XXX XXX XXX 284,079 0 55,572 286,270,864 (63,183,179) 0 0 223,087,685 0 0 0 804,586 532,429,569 295,425,764 804,586 532,429,569 295,425,764 XXX XXX XXX 804,586 532,429,569 295,425,764 0 0 17,734 XXX XXX 0 0 0 0 237,826,125 (46,623,230) 0 0 191,202,895 0 17,734 0 237,826,125 (46,623,230) 0 0 0 0 0 191,202,895 0 17,734 0 237,826,125 (46,623,230) 0 0 0 0 0 191,202,895 0 0 2,363,269 2,363,269 0 0 0 0 850,213 3,213,482 0 0 0 0 0 2,363,269 0.839 2,363,269 XXX 850,213 XXX 3,213,482 XXX 0 0 0.000 5,270,974 5,270,974 0.018 0 5,270,974 5,270,974 XXX 2,040,512 2,040,512 XXX 0 7,311,486 7,311,486 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 314,110,854 27,500,339 284,079 0 55,572 286,270,864 (63,183,179) 0 0 223,087,685 XXX XXX XXX 0 314,110,854 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,347 7,766,684 0 0 0 0 0 0 0 0 0 0 0 16,819,395 0 0 0 0 0 0 0 0 0 0 0 24,588,426 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 2,347 7,766,684 0 16,819,395 0 24,588,426 0 7,118,065 7,118,065 0 23,937,460 0 31,706,491 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 10,375,799 10,375,799 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14,384,628 XXX 14,384,628 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (337,879) (337,879) 14,046,749 XXX 2,347 7,766,684 (10,346,669) XXX 0 XXX 14,413,758 OTHER INDICATORS: 216-2.FL 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 412,001 412,001 77,892 489,893 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 412,001 412,001 77,892 489,893 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 4,897,583 934,265 5,831,848 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 4,897,583 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Florida DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.FL Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 314,276,387 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,821,792 713,563 1,730,769 (1,017,206) 165,533 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 314,110,854 (8,427) (63,183,179) (8,427) 0 0 0 0 0 0 0 0 0 0 250,123,089 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 245,477,169 714,929 320,107 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,821,792 713,563 1,730,769 17,734 55,195 4,224 41,685 8,868,186 44,189,115 35,320,929 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 237,826,125 (16,685) (46,623,230) (16,685) 0 0 0 0 0 0 0 0 0 0 190,398,309 314,276,387 0 0 0 1,821,792 713,563 1,730,769 (1,017,206) 165,533 0 314,110,854 (8,427) (63,183,179) (8,427) 0 250,123,089 245,477,169 714,929 320,107 0 0 0 0 1,821,792 713,563 1,730,769 17,734 55,195 4,224 41,685 8,868,186 44,189,115 35,320,929 0 0 237,826,125 (16,685) (46,623,230) (16,685) 0 190,398,309 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Florida DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.FL Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.FL 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.FL 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821611100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Georgia DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.GA 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 105,145,127 105,145,127 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 105,145,127 (761,774) 105,145,127 (761,774) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18,602 105,793,207 (21,562,910) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 94,985,177 (19,113,376) 0 0 75,871,801 0 0 791,086 791,086 0 0 0 0 284,599 1,075,685 0 0 0 0 0 791,086 0.905 791,086 XXX 284,599 XXX 1,075,685 XXX 0 0 0.000 1,764,418 1,764,418 0.017 0 1,764,418 1,764,418 XXX 683,039 683,039 XXX 0 2,447,457 2,447,457 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 95,092 0 XXX 0 0 0.000 0 84,230,297 XXX XXX XXX XXX XXX 95,092 0 18,602 105,793,207 (21,562,910) 0 0 84,230,297 (2,182,732) 218,271,589 121,110,950 (2,182,732) 218,271,589 121,110,950 XXX XXX XXX (2,182,732) 218,271,589 121,110,950 0 7,270 0 94,985,177 (19,113,376) 0 0 0 0 0 75,871,801 XXX XXX 0 7,270 0 94,985,177 (19,113,376) 0 0 0 0 0 75,871,801 7,270 0 105,145,127 (761,774) 95,092 0 18,602 105,793,207 (21,562,910) 0 0 84,230,297 XXX XXX XXX XXX 105,145,127 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 786 2,599,838 786 2,599,838 0 0 0 0 0 0 0 0 0 0 0 5,630,164 0 0 0 0 0 0 0 0 0 0 0 8,230,788 0 5,630,164 0 8,230,788 0 0 0 0 0 0 0 0 0 0 0 (2,427,796) (2,427,796) XXX 0 2,382,693 2,382,693 XXX 786 2,599,838 0 8,012,857 0 10,613,481 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (5,778,127) 3,473,183 434,416 XXX 434,416 XXX (1,993,380) 3,473,183 0 XXX (1,870,528) OTHER INDICATORS: 216-2.GA 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 180,125 180,125 14,546 194,671 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 180,125 180,125 14,546 194,671 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 2 2 4. Member Months 0 0 0 0 0 0 0 0 0 2,143,916 174,509 2,318,425 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 2,143,916 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Georgia DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.GA Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 105,201,620 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (1,431,672) 243,522 994,582 (751,060) 56,493 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 105,145,127 (3,068) (21,562,910) (3,068) 0 0 0 0 0 0 0 0 0 0 85,764,949 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 92,213,976 293,088 208,241 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (1,431,672) 243,522 994,582 7,270 32,653 1,732 27,115 (4,861,816) 18,115,501 22,977,317 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 94,985,177 (6,188) (19,113,376) (6,188) 0 0 0 0 0 0 0 0 0 0 78,054,533 105,201,620 0 0 0 (1,431,672) 243,522 994,582 (751,060) 56,493 0 105,145,127 (3,068) (21,562,910) (3,068) 0 85,764,949 92,213,976 293,088 208,241 0 0 0 0 (1,431,672) 243,522 994,582 7,270 32,653 1,732 27,115 (4,861,816) 18,115,501 22,977,317 0 0 94,985,177 (6,188) (19,113,376) (6,188) 0 78,054,533 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Georgia DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.GA Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.GA 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.GA 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821612100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Hawaii DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.HI 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 5,130,469 5,130,469 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,130,469 (19,477) 5,130,469 (19,477) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 908 5,144,398 (843,164) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 4,301,234 XXX XXX XXX XXX XXX 4,640 0 908 5,144,398 (843,164) 0 0 4,301,234 0 0 0 936,739 8,232,808 4,568,085 936,739 8,232,808 4,568,085 XXX XXX XXX 936,739 8,232,808 4,568,085 0 0 274 XXX XXX 0 0 0 0 4,601,736 (720,922) 0 0 3,880,814 0 274 0 4,601,736 (720,922) 0 0 0 0 0 3,880,814 0 274 0 4,601,736 (720,922) 0 0 0 0 0 3,880,814 0 0 38,596 38,596 0 0 0 0 13,887 52,483 0 0 0 0 0 38,596 0.902 38,596 XXX 13,887 XXX 52,483 XXX 0 0 0.000 86,084 86,084 0.017 0 86,084 86,084 XXX 33,328 33,328 XXX 0 119,412 119,412 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 5,130,469 (19,477) 4,640 0 908 5,144,398 (843,164) 0 0 4,301,234 XXX XXX XXX 4,640 5,130,469 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 38 126,843 38 126,843 0 0 0 0 0 0 0 0 0 0 0 274,690 0 0 0 0 0 0 0 0 0 0 0 401,571 0 274,690 0 401,571 0 0 0 0 0 0 0 0 0 0 0 (105,831) (105,831) 0 116,262 116,262 0 390,952 0 517,833 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 38 126,843 (269,308) 169,471 20,451 XXX 20,451 XXX (85,380) 169,471 0 XXX (79,386) OTHER INDICATORS: 216-2.HI 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 8,371 8,371 39,579 47,950 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 8,371 8,371 39,579 47,950 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 102,084 468,837 570,921 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 102,084 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Hawaii DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.HI Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 5,132,678 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,350,566 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,500,753 11,055 7,650 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 963,049 9,522 35,832 274 1,203 65 994 (160,565) 683,284 843,849 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,601,736 (55) (720,922) (55) 0 0 0 0 0 0 0 0 0 0 2,944,075 0 963,049 9,522 35,832 (26,310) 2,209 5,130,469 (843,164) 5,132,678 0 0 0 963,049 9,522 35,832 (26,310) 2,209 0 5,130,469 0 (843,164) 0 0 3,350,566 3,500,753 11,055 7,650 0 0 0 0 963,049 9,522 35,832 274 1,203 65 994 (160,565) 683,284 843,849 0 0 4,601,736 (55) (720,922) (55) 0 2,944,075 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Hawaii DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 216-4.HI 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.HI 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.HI 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821613100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Idaho DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.ID 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 15,451,951 15,451,951 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15,451,951 851,056 15,451,951 851,056 XXX 0 0 0 0 0 0 0 0 0 0 0 13,975 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,734 14,584,186 (3,014,738) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 11,569,448 XXX XXX XXX XXX XXX 13,975 0 2,734 14,584,186 (3,014,738) 0 0 11,569,448 0 0 0 441,945 25,865,880 14,352,034 441,945 25,865,880 14,352,034 XXX XXX XXX 441,945 25,865,880 14,352,034 0 0 862 XXX XXX 0 0 0 0 11,956,653 (2,264,996) 0 0 9,691,657 0 862 0 11,956,653 (2,264,996) 0 0 0 0 0 9,691,657 0 862 0 11,956,653 (2,264,996) 0 0 0 0 0 9,691,657 0 0 116,254 116,254 0 0 0 0 41,824 158,078 0 0 0 0 0 116,254 0.828 116,254 XXX 41,824 XXX 158,078 XXX 0 0 0.000 259,289 259,289 0.018 0 259,289 259,289 XXX 100,378 100,378 XXX 0 359,667 359,667 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 15,451,951 851,056 13,975 0 2,734 14,584,186 (3,014,738) 0 0 11,569,448 XXX XXX XXX 0 15,451,951 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 115 382,058 115 382,058 0 0 0 0 0 0 0 0 0 0 0 827,378 0 0 0 0 0 0 0 0 0 0 0 1,209,551 0 827,378 0 1,209,551 0 0 0 0 0 0 0 0 0 0 0 292,697 292,697 0 350,157 350,157 0 1,177,535 0 1,559,708 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 115 382,058 (199,662) 510,413 61,249 353,946 XXX 510,413 61,249 XXX 0 XXX 372,000 OTHER INDICATORS: 216-2.ID 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 22,418 22,418 1,791 24,209 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 22,418 22,418 1,791 24,209 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 265,270 21,659 286,929 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 265,270 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Idaho DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.ID Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 15,459,849 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 551,313 34,047 143,415 (109,368) 7,898 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15,451,951 (141) (3,014,738) (141) 0 0 0 0 0 0 0 0 0 0 11,995,268 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,074,486 34,732 23,335 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 551,313 34,047 143,415 862 3,695 205 3,038 (427,963) 2,146,745 2,574,708 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,956,653 (458) (2,264,996) (458) 0 0 0 0 0 0 0 0 0 0 9,249,712 15,459,849 0 0 0 551,313 34,047 143,415 (109,368) 7,898 0 15,451,951 (141) (3,014,738) (141) 0 11,995,268 11,074,486 34,732 23,335 0 0 0 0 551,313 34,047 143,415 862 3,695 205 3,038 (427,963) 2,146,745 2,574,708 0 0 11,956,653 (458) (2,264,996) (458) 0 9,249,712 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Idaho DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 216-4.ID 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.ID 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.ID 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821614100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Illinois DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.IL 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 104,633,842 104,633,842 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 104,633,842 2,473,233 104,633,842 2,473,233 XXX 0 0 0 0 0 0 0 0 0 0 0 94,630 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18,512 102,047,467 (21,126,964) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 87,782,615 (17,370,775) 0 0 70,411,840 0 0 787,233 787,233 0 0 0 0 283,216 1,070,449 0 0 0 0 0 787,233 0.868 787,233 XXX 283,216 XXX 1,070,449 XXX 0 0 0.000 1,755,824 1,755,824 0.017 0 1,755,824 1,755,824 XXX 679,717 679,717 XXX 0 2,435,541 2,435,541 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 80,920,503 XXX XXX XXX XXX XXX 94,630 0 18,512 102,047,467 (21,126,964) 0 0 80,920,503 (526,321) 198,371,376 110,069,047 (526,321) 198,371,376 110,069,047 XXX XXX XXX (526,321) 198,371,376 110,069,047 0 6,607 0 87,782,615 (17,370,775) 0 0 0 0 0 70,411,840 XXX XXX 0 6,607 0 87,782,615 (17,370,775) 0 0 0 0 0 70,411,840 6,607 0 104,633,842 2,473,233 94,630 0 18,512 102,047,467 (21,126,964) 0 0 80,920,503 XXX XXX XXX XXX 104,633,842 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 782 2,587,175 0 0 0 0 0 0 0 0 0 0 0 5,602,740 0 0 0 0 0 0 0 0 0 0 0 8,190,697 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 782 2,587,175 0 5,602,740 0 8,190,697 0 2,371,107 2,371,107 0 7,973,847 0 10,561,804 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (225,091) (225,091) XXX XXX 782 2,587,175 (3,559,131) 3,456,295 412,001 186,910 XXX 3,456,295 412,001 XXX 0 XXX 309,165 OTHER INDICATORS: 216-2.IL 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 177,890 177,890 30,966 208,856 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 177,890 177,890 30,966 208,856 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 11 11 4. Member Months 0 0 0 0 0 0 0 0 0 2,104,174 376,488 2,480,662 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 2,104,174 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Illinois DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.IL Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 104,689,192 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 211,749 238,599 976,669 (738,070) 55,350 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 104,633,842 (5,642) (21,126,964) (5,642) 0 0 0 0 0 0 0 0 0 0 84,033,199 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 85,515,176 266,366 173,628 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 211,749 238,599 976,669 6,607 27,643 1,574 22,610 (2,694,415) 16,463,878 19,158,293 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 87,782,615 (7,404) (17,370,775) (7,404) 0 0 0 0 0 0 0 0 0 0 70,938,161 104,689,192 0 0 0 211,749 238,599 976,669 (738,070) 55,350 0 104,633,842 (5,642) (21,126,964) (5,642) 0 84,033,199 85,515,176 266,366 173,628 0 0 0 0 211,749 238,599 976,669 6,607 27,643 1,574 22,610 (2,694,415) 16,463,878 19,158,293 0 0 87,782,615 (7,404) (17,370,775) (7,404) 0 70,938,161 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Illinois DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 216-4.IL 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.IL 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.IL 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821615100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Indiana DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.IN 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 69,522,648 69,522,648 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 69,522,648 (2,787,560) 69,522,648 (2,787,560) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,300 72,235,032 (14,077,792) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 67,542,458 (13,392,372) 0 0 54,150,086 0 0 523,068 523,068 0 0 0 0 188,179 711,247 0 0 0 0 0 523,068 0.942 523,068 XXX 188,179 XXX 711,247 XXX 0 0 0.000 1,166,637 1,166,637 0.016 0 1,166,637 1,166,637 XXX 451,630 451,630 XXX 0 1,618,267 1,618,267 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 62,876 0 XXX 0 0 0.000 0 58,157,240 XXX XXX XXX XXX XXX 62,876 0 12,300 72,235,032 (14,077,792) 0 0 58,157,240 (541,209) 152,938,664 84,860,091 (541,209) 152,938,664 84,860,091 XXX XXX XXX (541,209) 152,938,664 84,860,091 0 5,094 0 67,542,458 (13,392,372) 0 0 0 0 0 54,150,086 XXX XXX 0 5,094 0 67,542,458 (13,392,372) 0 0 0 0 0 54,150,086 5,094 0 69,522,648 (2,787,560) 62,876 0 12,300 72,235,032 (14,077,792) 0 0 58,157,240 XXX XXX XXX XXX 69,522,648 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 519 1,719,018 519 1,719,018 0 0 0 0 0 0 0 0 0 0 0 3,722,676 0 0 0 0 0 0 0 0 0 0 0 5,442,213 0 3,722,676 0 5,442,213 0 0 0 0 0 0 0 0 0 0 0 (3,124,764) (3,124,764) XXX 0 1,575,452 1,575,452 XXX 519 1,719,018 0 5,298,128 0 7,017,665 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 2,296,492 272,561 XXX XXX (2,852,203) XXX (5,340,025) 2,296,492 272,561 0 (2,770,972) OTHER INDICATORS: 216-2.IN 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 114,941 114,941 14,337 129,278 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 114,941 114,941 14,337 129,278 3. Number of Groups 4. Member Months 165,525 1,531,329 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 1,365,804 1,365,804 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Indiana DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.IN Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 69,559,530 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (58,222) 158,988 641,975 (482,987) 36,882 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 69,522,648 (4,628) (14,077,792) (4,628) 0 0 0 0 0 0 0 0 0 0 55,986,065 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 66,257,825 205,361 130,862 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (58,222) 158,988 641,975 5,094 20,922 1,213 17,041 (1,746,249) 12,693,180 14,439,429 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 67,542,458 (6,187) (13,392,372) (6,187) 0 0 0 0 0 0 0 0 0 0 54,691,295 69,559,530 0 0 0 (58,222) 158,988 641,975 (482,987) 36,882 0 69,522,648 (4,628) (14,077,792) (4,628) 0 55,986,065 66,257,825 205,361 130,862 0 0 0 0 (58,222) 158,988 641,975 5,094 20,922 1,213 17,041 (1,746,249) 12,693,180 14,439,429 0 0 67,542,458 (6,187) (13,392,372) (6,187) 0 54,691,295 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Indiana DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 216-4.IN 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.IN 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.IN 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821616100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Iowa DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.IA 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 42,763,482 42,763,482 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42,763,482 2,021,477 42,763,482 2,021,477 XXX 0 0 0 0 0 0 0 0 0 0 0 38,675 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,566 40,695,764 (8,654,998) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35,743,089 (7,094,873) 0 0 28,648,216 0 0 321,740 321,740 0 0 0 0 115,749 437,489 0 0 0 0 0 321,740 0.886 321,740 XXX 115,749 XXX 437,489 XXX 0 0 0.000 717,600 717,600 0.018 0 717,600 717,600 XXX 277,798 277,798 XXX 0 995,398 995,398 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 32,040,766 XXX XXX XXX XXX XXX 38,675 0 7,566 40,695,764 (8,654,998) 0 0 32,040,766 (325,575) 81,022,270 44,956,305 (325,575) 81,022,270 44,956,305 XXX XXX XXX (325,575) 81,022,270 44,956,305 0 2,699 0 35,743,089 (7,094,873) 0 0 0 0 0 28,648,216 XXX XXX 0 2,699 0 35,743,089 (7,094,873) 0 0 0 0 0 28,648,216 2,699 0 42,763,482 2,021,477 38,675 0 7,566 40,695,764 (8,654,998) 0 0 32,040,766 XXX XXX XXX XXX 42,763,482 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 319 1,057,370 0 0 0 0 0 0 0 0 0 0 0 2,289,823 0 0 0 0 0 0 0 0 0 0 0 3,347,512 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 319 1,057,370 0 2,289,823 0 3,347,512 0 969,063 969,063 0 3,258,886 0 4,316,575 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (994,302) (994,302) XXX XXX 319 1,057,370 (2,356,912) 1,412,575 1,749,603 755,301 XXX 1,412,575 1,749,603 XXX 0 XXX 805,266 OTHER INDICATORS: 216-2.IA 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 59,673 59,673 3,172 62,845 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 59,673 59,673 3,172 62,845 3. Number of Groups 4. Member Months 43,292 756,650 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 713,358 713,358 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Iowa DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.IA Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 42,786,157 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (14,696) 97,746 408,625 (310,879) 22,675 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42,763,482 (169) (8,654,998) (169) 0 0 0 0 0 0 0 0 0 0 34,434,059 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 34,536,143 108,794 74,494 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (14,696) 97,746 408,625 2,699 11,759 643 9,703 (1,495,522) 6,724,462 8,219,984 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35,743,089 (1,223) (7,094,873) (1,223) 0 0 0 0 0 0 0 0 0 0 28,973,791 42,786,157 0 0 0 (14,696) 97,746 408,625 (310,879) 22,675 0 42,763,482 (169) (8,654,998) (169) 0 34,434,059 34,536,143 108,794 74,494 0 0 0 0 (14,696) 97,746 408,625 2,699 11,759 643 9,703 (1,495,522) 6,724,462 8,219,984 0 0 35,743,089 (1,223) (7,094,873) (1,223) 0 28,973,791 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Iowa DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 216-4.IA 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.IA 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.IA 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821617100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Kansas DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.KS 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 40,443,930 40,443,930 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40,443,930 (331,750) 40,443,930 (331,750) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,155 40,731,948 (8,182,282) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 36,602,863 (7,252,513) 0 0 29,350,350 0 0 304,288 304,288 0 0 0 0 109,471 413,759 0 0 0 0 0 304,288 0.906 304,288 XXX 109,471 XXX 413,759 XXX 0 0 0.000 678,676 678,676 0.017 0 678,676 678,676 XXX 262,730 262,730 XXX 0 941,406 941,406 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 36,577 0 XXX 0 0 0.000 0 32,549,666 XXX XXX XXX XXX XXX 36,577 0 7,155 40,731,948 (8,182,282) 0 0 32,549,666 (267,206) 82,822,493 45,955,183 (267,206) 82,822,493 45,955,183 XXX XXX XXX (267,206) 82,822,493 45,955,183 0 2,759 0 36,602,863 (7,252,513) 0 0 0 0 0 29,350,350 XXX XXX 0 2,759 0 36,602,863 (7,252,513) 0 0 0 0 0 29,350,350 2,759 0 40,443,930 (331,750) 36,577 0 7,155 40,731,948 (8,182,282) 0 0 32,549,666 XXX XXX XXX XXX 40,443,930 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 302 1,000,017 0 0 0 0 0 0 0 0 0 0 0 2,165,619 0 0 0 0 0 0 0 0 0 0 0 3,165,938 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 302 1,000,017 0 2,165,619 0 3,165,938 0 916,500 916,500 0 3,082,119 0 4,082,438 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (949,586) (949,586) XXX XXX 302 1,000,017 (2,238,287) 1,335,956 156,816 XXX 156,816 XXX (792,770) 1,335,956 0 XXX (745,515) OTHER INDICATORS: 216-2.KS 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 70,557 70,557 5,009 75,566 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 70,557 70,557 5,009 75,566 3. Number of Groups 4. Member Months 60,187 893,278 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 833,091 833,091 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Kansas DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.KS Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 40,465,367 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,197 92,407 361,810 (269,403) 21,437 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40,443,930 (1,382) (8,182,282) (1,382) 0 0 0 0 0 0 0 0 0 0 32,528,854 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35,694,471 111,211 72,575 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,197 92,407 361,810 2,759 11,554 657 9,452 (1,134,203) 6,873,872 8,008,075 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 36,602,863 (1,814) (7,252,513) (1,814) 0 0 0 0 0 0 0 0 0 0 29,617,556 40,465,367 0 0 0 2,197 92,407 361,810 (269,403) 21,437 0 40,443,930 (1,382) (8,182,282) (1,382) 0 32,528,854 35,694,471 111,211 72,575 0 0 0 0 2,197 92,407 361,810 2,759 11,554 657 9,452 (1,134,203) 6,873,872 8,008,075 0 0 36,602,863 (1,814) (7,252,513) (1,814) 0 29,617,556 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Kansas DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.KS Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.KS 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.KS 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821618100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Kentucky DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.KY 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 59,822,980 59,822,980 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 59,822,980 (742,373) 59,822,980 (742,373) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,584 60,500,666 (12,114,028) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 54,673,414 (10,848,255) 0 0 43,825,159 0 0 450,090 450,090 0 0 0 0 161,925 612,015 0 0 0 0 0 450,090 0.911 450,090 XXX 161,925 XXX 612,015 XXX 0 0 0.000 1,003,870 1,003,870 0.017 0 1,003,870 1,003,870 XXX 388,619 388,619 XXX 0 1,392,489 1,392,489 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 54,103 0 XXX 0 0 0.000 0 48,386,638 XXX XXX XXX XXX XXX 54,103 0 10,584 60,500,666 (12,114,028) 0 0 48,386,638 (476,563) 123,885,275 68,739,424 (476,563) 123,885,275 68,739,424 XXX XXX XXX (476,563) 123,885,275 68,739,424 0 4,126 0 54,673,414 (10,848,255) 0 0 0 0 0 43,825,159 XXX XXX 0 4,126 0 54,673,414 (10,848,255) 0 0 0 0 0 43,825,159 4,126 0 59,822,980 (742,373) 54,103 0 10,584 60,500,666 (12,114,028) 0 0 48,386,638 XXX XXX XXX XXX 59,822,980 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 447 1,479,184 447 1,479,184 0 0 0 0 0 0 0 0 0 0 0 3,203,295 0 0 0 0 0 0 0 0 0 0 0 4,682,926 0 3,203,295 0 4,682,926 0 0 0 0 0 0 0 0 0 0 0 (1,575,407) (1,575,407) XXX 0 1,355,648 1,355,648 XXX 447 1,479,184 0 4,558,943 0 6,038,574 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (3,481,599) 1,976,090 233,722 XXX 233,722 XXX (1,341,685) 1,976,090 0 XXX (1,271,787) OTHER INDICATORS: 216-2.KY 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 92,571 92,571 7,077 99,648 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 92,571 92,571 7,077 99,648 3. Number of Groups 4. Member Months 85,758 1,197,284 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 1,111,526 1,111,526 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Kentucky DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.KY Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 59,854,717 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (51,791) 136,810 561,582 (424,772) 31,737 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 59,822,980 (815) (12,114,028) (815) 0 0 0 0 0 0 0 0 0 0 48,185,515 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53,087,295 166,349 111,340 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (51,791) 136,810 561,582 4,126 17,642 983 14,499 (2,003,547) 10,281,887 12,285,434 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 54,673,414 (2,700) (10,848,255) (2,700) 0 0 0 0 0 0 0 0 0 0 44,301,722 59,854,717 0 0 0 (51,791) 136,810 561,582 (424,772) 31,737 0 59,822,980 (815) (12,114,028) (815) 0 48,185,515 53,087,295 166,349 111,340 0 0 0 0 (51,791) 136,810 561,582 4,126 17,642 983 14,499 (2,003,547) 10,281,887 12,285,434 0 0 54,673,414 (2,700) (10,848,255) (2,700) 0 44,301,722 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Kentucky DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.KY Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.KY 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.KY 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821619100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Louisiana DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.LA 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 65,453,936 65,453,936 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 65,453,936 3,842,227 65,453,936 3,842,227 XXX 0 0 0 0 0 0 0 0 0 0 0 59,196 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,580 61,540,933 (14,083,831) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53,829,842 (11,495,321) 0 0 42,334,521 0 0 492,472 492,472 0 0 0 0 177,166 669,638 0 0 0 0 0 492,472 0.883 492,472 XXX 177,166 XXX 669,638 XXX 0 0 0.000 1,098,398 1,098,398 0.018 0 1,098,398 1,098,398 XXX 425,199 425,199 XXX 0 1,523,597 1,523,597 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 47,457,102 XXX XXX XXX XXX XXX 59,196 0 11,580 61,540,933 (14,083,831) 0 0 47,457,102 (4,609,670) 131,274,670 72,839,530 (4,609,670) 131,274,670 72,839,530 XXX XXX XXX (4,609,670) 131,274,670 72,839,530 0 4,372 0 53,829,842 (11,495,321) 0 0 0 0 0 42,334,521 XXX XXX 0 4,372 0 53,829,842 (11,495,321) 0 0 0 0 0 42,334,521 4,372 0 65,453,936 3,842,227 59,196 0 11,580 61,540,933 (14,083,831) 0 0 47,457,102 XXX XXX XXX XXX 65,453,936 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 489 1,618,469 489 1,618,469 0 0 0 0 0 0 0 0 0 0 0 3,504,928 0 0 0 0 0 0 0 0 0 0 0 5,123,886 0 3,504,928 0 5,123,886 0 0 0 0 0 0 0 0 0 0 0 (1,592,175) (1,592,175) XXX 0 1,483,251 1,483,251 XXX 489 1,618,469 0 4,988,179 0 6,607,137 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (3,677,791) 2,162,093 3,250,800 1,658,625 XXX 2,162,093 3,250,800 XXX 0 XXX 1,735,102 OTHER INDICATORS: 216-2.LA 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 96,495 96,495 4,907 101,402 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 96,495 96,495 4,907 101,402 3. Number of Groups 4. Member Months 59,203 1,215,150 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 1,155,947 1,155,947 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Louisiana DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.LA Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 65,490,834 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (4,156,782) 159,057 611,945 (452,888) 36,898 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 65,453,936 (1,589) (14,083,831) (1,589) 0 0 0 0 0 0 0 0 0 0 55,979,775 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 55,540,995 176,272 124,501 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (4,156,782) 159,057 611,945 4,372 19,543 1,041 16,212 (2,842,374) 10,895,171 13,737,545 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53,829,842 (3,542) (11,495,321) (3,542) 0 0 0 0 0 0 0 0 0 0 46,944,191 65,490,834 0 0 0 (4,156,782) 159,057 611,945 (452,888) 36,898 0 65,453,936 (1,589) (14,083,831) (1,589) 0 55,979,775 55,540,995 176,272 124,501 0 0 0 0 (4,156,782) 159,057 611,945 4,372 19,543 1,041 16,212 (2,842,374) 10,895,171 13,737,545 0 0 53,829,842 (3,542) (11,495,321) (3,542) 0 46,944,191 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Louisiana DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.LA Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.LA 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.LA 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821620100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Maine DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.ME 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 7,910,249 7,910,249 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,910,249 210,261 7,910,249 210,261 XXX 0 0 0 0 0 0 0 0 0 0 0 7,154 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,399 7,691,435 (1,522,547) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 6,168,888 XXX XXX XXX XXX XXX 7,154 0 1,399 7,691,435 (1,522,547) 0 0 6,168,888 0 0 0 339,537 14,045,343 7,793,249 339,537 14,045,343 7,793,249 XXX XXX XXX 339,537 14,045,343 7,793,249 0 0 468 XXX XXX 0 0 0 0 6,592,099 (1,229,908) 0 0 5,362,191 0 468 0 6,592,099 (1,229,908) 0 0 0 0 0 5,362,191 0 468 0 6,592,099 (1,229,908) 0 0 0 0 0 5,362,191 0 0 59,513 59,513 0 0 0 0 21,411 80,924 0 0 0 0 0 59,513 0.865 59,513 XXX 21,411 XXX 80,924 XXX 0 0 0.000 132,736 132,736 0.017 0 132,736 132,736 XXX 51,386 51,386 XXX 0 184,122 184,122 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 7,910,249 210,261 7,154 0 1,399 7,691,435 (1,522,547) 0 0 6,168,888 XXX XXX XXX 0 7,910,249 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 59 195,584 0 0 0 0 0 0 0 0 0 0 0 423,553 0 0 0 0 0 0 0 0 0 0 0 619,196 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 59 195,584 0 423,553 0 619,196 0 179,254 179,254 0 602,807 0 798,450 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (4,748) (4,748) XXX XXX 59 195,584 (256,799) 261,293 34,520 29,772 XXX 261,293 34,520 XXX 0 XXX 39,014 OTHER INDICATORS: 216-2.ME 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 11,864 11,864 3,166 15,030 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 11,864 11,864 3,166 15,030 3. Number of Groups 4. Member Months 37,444 175,457 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 138,013 138,013 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Maine DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.ME Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 7,914,238 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 384,910 17,195 62,568 (45,373) 3,989 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,910,249 (79) (1,522,547) (79) 0 0 0 0 0 0 0 0 0 0 6,048,165 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6,222,473 18,860 10,760 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 384,910 17,195 62,568 468 1,758 111 1,401 (21,521) 1,165,697 1,187,218 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6,592,099 (596) (1,229,908) (596) 0 0 0 0 0 0 0 0 0 0 5,022,654 7,914,238 0 0 0 384,910 17,195 62,568 (45,373) 3,989 0 7,910,249 (79) (1,522,547) (79) 0 6,048,165 6,222,473 18,860 10,760 0 0 0 0 384,910 17,195 62,568 468 1,758 111 1,401 (21,521) 1,165,697 1,187,218 0 0 6,592,099 (596) (1,229,908) (596) 0 5,022,654 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Maine DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.ME Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.ME 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.ME 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821621100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Maryland DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.MD 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 58,453,529 58,453,529 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 58,453,529 4,115,383 58,453,529 4,115,383 XXX 0 0 0 0 0 0 0 0 0 0 0 52,865 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,342 54,274,939 (11,579,167) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 42,695,772 XXX XXX XXX XXX XXX 52,865 0 10,342 54,274,939 (11,579,167) 0 0 42,695,772 0 0 0 863,921 95,434,332 52,953,033 863,921 95,434,332 52,953,033 XXX XXX XXX 863,921 95,434,332 52,953,033 0 0 3,179 XXX XXX 0 0 0 0 43,348,399 (8,356,893) 0 0 34,991,506 0 3,179 0 43,348,399 (8,356,893) 0 0 0 0 0 34,991,506 0 3,179 0 43,348,399 (8,356,893) 0 0 0 0 0 34,991,506 0 0 439,782 439,782 0 0 0 0 158,218 598,000 0 0 0 0 0 439,782 0.807 439,782 XXX 158,218 XXX 598,000 XXX 0 0 0.000 980,878 980,878 0.018 0 980,878 980,878 XXX 379,723 379,723 XXX 0 1,360,601 1,360,601 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 58,453,529 4,115,383 52,865 0 10,342 54,274,939 (11,579,167) 0 0 42,695,772 XXX XXX XXX 0 58,453,529 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 437 1,445,306 437 1,445,306 0 0 0 0 0 0 0 0 0 0 0 3,129,930 0 0 0 0 0 0 0 0 0 0 0 4,575,673 0 3,129,930 0 4,575,673 0 0 0 0 0 0 0 0 0 0 0 1,707,933 1,707,933 0 1,324,615 1,324,615 0 4,454,545 0 5,900,288 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 437 1,445,306 (154,623) 1,930,853 232,830 1,940,763 XXX 1,930,853 232,830 XXX 0 XXX 2,009,060 OTHER INDICATORS: 216-2.MD 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 77,601 77,601 88,120 165,721 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 77,601 77,601 88,120 165,721 3. Number of Groups 0 0 0 0 0 0 0 0 0 1 1 15 16 4. Member Months 0 0 0 0 0 0 0 0 0 918,658 918,658 1,045,524 1,964,182 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Maryland DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.MD Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 58,483,865 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,222,362 130,770 489,211 (358,441) 30,336 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 58,453,529 (5,083) (11,579,167) (5,083) 0 0 0 0 0 0 0 0 0 0 46,010,441 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40,690,454 128,146 87,643 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,222,362 130,770 489,211 3,179 13,838 757 11,416 (1,750,342) 7,920,594 9,670,936 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43,348,399 (5,633) (8,356,893) (5,633) 0 0 0 0 0 0 0 0 0 0 34,127,585 58,483,865 0 0 0 1,222,362 130,770 489,211 (358,441) 30,336 0 58,453,529 (5,083) (11,579,167) (5,083) 0 46,010,441 40,690,454 128,146 87,643 0 0 0 0 1,222,362 130,770 489,211 3,179 13,838 757 11,416 (1,750,342) 7,920,594 9,670,936 0 0 43,348,399 (5,633) (8,356,893) (5,633) 0 34,127,585 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Maryland DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.MD Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.MD 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.MD 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821622100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Massachusetts DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.MA 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 98,981,685 98,981,685 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 98,981,685 8,147,064 98,981,685 8,147,064 XXX 0 0 0 0 0 0 0 0 0 0 0 89,518 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17,512 90,727,591 (20,025,857) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 70,958,289 (14,100,304) 0 0 56,857,985 0 0 744,709 744,709 0 0 0 0 267,917 1,012,626 0 0 0 0 0 744,709 0.790 744,709 XXX 267,917 XXX 1,012,626 XXX 0 0 0.000 1,660,979 1,660,979 0.018 0 1,660,979 1,660,979 XXX 643,000 643,000 XXX 0 2,303,979 2,303,979 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 70,701,734 XXX XXX XXX XXX XXX 89,518 0 17,512 90,727,591 (20,025,857) 0 0 70,701,734 (724,342) 161,023,140 89,345,872 (724,342) 161,023,140 89,345,872 XXX XXX XXX (724,342) 161,023,140 89,345,872 0 5,363 0 70,958,289 (14,100,304) 0 0 0 0 0 56,857,985 XXX XXX 0 5,363 0 70,958,289 (14,100,304) 0 0 0 0 0 56,857,985 5,363 0 98,981,685 8,147,064 89,518 0 17,512 90,727,591 (20,025,857) 0 0 70,701,734 XXX XXX XXX XXX 98,981,685 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 739 2,447,422 739 2,447,422 0 0 0 0 0 0 0 0 0 0 0 5,300,094 0 0 0 0 0 0 0 0 0 0 0 7,748,255 0 5,300,094 0 7,748,255 0 0 0 0 0 0 0 0 0 0 0 3,689,806 3,689,806 0 2,243,024 2,243,024 0 7,543,118 0 9,991,279 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 739 2,447,422 535,865 3,269,592 388,091 4,077,897 XXX 3,269,592 388,091 XXX 0 XXX 4,193,548 OTHER INDICATORS: 216-2.MA 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 115,656 115,656 97,767 213,423 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 115,656 115,656 97,767 213,423 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 2 2 4. Member Months 0 0 0 0 0 0 0 0 0 1,421,677 1,127,749 2,549,426 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 1,421,677 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Massachusetts DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.MA Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 99,034,151 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,923 226,163 952,428 (726,265) 52,466 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 98,981,685 (2,808) (20,025,857) (2,808) 0 0 0 0 0 0 0 0 0 0 79,680,170 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 67,427,282 216,216 159,114 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,923 226,163 952,428 5,363 24,807 1,278 20,722 (4,192,884) 13,364,152 17,557,036 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 70,958,289 (5,846) (14,100,304) (5,846) 0 0 0 0 0 0 0 0 0 0 57,582,327 99,034,151 0 0 0 1,923 226,163 952,428 (726,265) 52,466 0 98,981,685 (2,808) (20,025,857) (2,808) 0 79,680,170 67,427,282 216,216 159,114 0 0 0 0 1,923 226,163 952,428 5,363 24,807 1,278 20,722 (4,192,884) 13,364,152 17,557,036 0 0 70,958,289 (5,846) (14,100,304) (5,846) 0 57,582,327 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Massachusetts DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.MA Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.MA 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.MA 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821623100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Michigan DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.MI 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 79,977,764 79,977,764 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 79,977,764 2,793,729 79,977,764 2,793,729 XXX 0 0 0 0 0 0 0 0 0 0 0 72,331 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14,150 77,097,554 (15,130,813) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 61,966,741 XXX XXX XXX XXX XXX 72,331 0 14,150 77,097,554 (15,130,813) 0 0 61,966,741 0 0 0 4,667,098 136,082,102 75,506,999 4,667,098 136,082,102 75,506,999 XXX XXX XXX 4,667,098 136,082,102 75,506,999 0 0 4,533 XXX XXX 0 0 0 0 65,246,734 (11,916,294) 0 0 53,330,440 0 4,533 0 65,246,734 (11,916,294) 0 0 0 0 0 53,330,440 0 4,533 0 65,246,734 (11,916,294) 0 0 0 0 0 53,330,440 0 0 601,708 601,708 0 0 0 0 216,478 818,186 0 0 0 0 0 601,708 0.854 601,708 XXX 216,478 XXX 818,186 XXX 0 0 0.000 1,342,034 1,342,034 0.017 0 1,342,034 1,342,034 XXX 519,548 519,548 XXX 0 1,861,582 1,861,582 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 79,977,764 2,793,729 72,331 0 14,150 77,097,554 (15,130,813) 0 0 61,966,741 XXX XXX XXX 0 79,977,764 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 597 1,977,463 597 1,977,463 0 0 0 0 0 0 0 0 0 0 0 4,282,359 0 0 0 0 0 0 0 0 0 0 0 6,260,419 0 4,282,359 0 6,260,419 0 0 0 0 0 0 0 0 0 0 0 432,140 432,140 0 1,812,376 1,812,376 0 6,094,735 0 8,072,795 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 597 1,977,463 (2,116,262) 2,641,849 317,504 749,644 XXX 2,641,849 317,504 XXX 0 XXX 843,091 OTHER INDICATORS: 216-2.MI 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 101,091 101,091 15,647 116,738 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 101,091 101,091 15,647 116,738 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 4 4 4. Member Months 0 0 0 0 0 0 0 0 0 1,202,136 186,972 1,389,108 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 1,202,136 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Michigan DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.MI Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 80,017,405 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,192,235 170,881 696,018 (525,137) 39,641 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 79,977,764 (4,057) (15,130,813) (4,057) 0 0 0 0 0 0 0 0 0 0 60,179,853 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 57,928,250 182,726 125,827 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,192,235 170,881 696,018 4,533 19,841 1,080 16,388 (2,589,954) 11,294,165 13,884,119 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 65,246,734 (11,296) (11,916,294) (11,296) 0 0 0 0 0 0 0 0 0 0 48,663,342 80,017,405 0 0 0 5,192,235 170,881 696,018 (525,137) 39,641 0 79,977,764 (4,057) (15,130,813) (4,057) 0 60,179,853 57,928,250 182,726 125,827 0 0 0 0 5,192,235 170,881 696,018 4,533 19,841 1,080 16,388 (2,589,954) 11,294,165 13,884,119 0 0 65,246,734 (11,296) (11,916,294) (11,296) 0 48,663,342 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Michigan DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 216-4.MI 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.MI 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.MI 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821624100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Minnesota DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.MN 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 48,950,298 48,950,298 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 48,950,298 3,128,745 48,950,298 3,128,745 XXX 0 0 0 0 0 0 0 0 0 0 0 44,270 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8,660 45,768,623 (9,907,392) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 39,325,859 (7,809,887) 0 0 31,515,972 0 0 368,288 368,288 0 0 0 0 132,495 500,783 0 0 0 0 0 368,288 0.867 368,288 XXX 132,495 XXX 500,783 XXX 0 0 0.000 821,419 821,419 0.018 0 821,419 821,419 XXX 317,989 317,989 XXX 0 1,139,408 1,139,408 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 35,861,231 XXX XXX XXX XXX XXX 44,270 0 8,660 45,768,623 (9,907,392) 0 0 35,861,231 (377,771) 89,187,618 49,486,959 (377,771) 89,187,618 49,486,959 XXX XXX XXX (377,771) 89,187,618 49,486,959 0 2,971 0 39,325,859 (7,809,887) 0 0 0 0 0 31,515,972 XXX XXX 0 2,971 0 39,325,859 (7,809,887) 0 0 0 0 0 31,515,972 2,971 0 48,950,298 3,128,745 44,270 0 8,660 45,768,623 (9,907,392) 0 0 35,861,231 XXX XXX XXX XXX 48,950,298 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 366 1,210,346 0 0 0 0 0 0 0 0 0 0 0 2,621,104 0 0 0 0 0 0 0 0 0 0 0 3,831,816 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 366 1,210,346 0 2,621,104 0 3,831,816 0 1,109,263 1,109,263 0 3,730,367 0 4,941,079 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (676,264) (676,264) XXX XXX 366 1,210,346 (2,236,011) 1,616,941 2,088,179 1,411,915 XXX 1,616,941 2,088,179 XXX 0 XXX 1,469,109 OTHER INDICATORS: 216-2.MN 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 71,517 71,517 1,466 72,983 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 71,517 71,517 1,466 72,983 3. Number of Groups 0 0 0 0 0 0 0 0 0 1 1 1 2 4. Member Months 0 0 0 0 0 0 0 0 0 847,860 847,860 17,931 865,791 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Minnesota DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.MN Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 48,976,254 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (17,957) 111,890 471,704 (359,814) 25,956 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 48,950,298 (760) (9,907,392) (760) 0 0 0 0 0 0 0 0 0 0 39,420,677 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 38,115,897 119,758 81,095 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (17,957) 111,890 471,704 2,971 12,825 708 10,562 (1,546,099) 7,402,147 8,948,246 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 39,325,859 (802) (7,809,887) (802) 0 0 0 0 0 0 0 0 0 0 31,893,743 48,976,254 0 0 0 (17,957) 111,890 471,704 (359,814) 25,956 0 48,950,298 (760) (9,907,392) (760) 0 39,420,677 38,115,897 119,758 81,095 0 0 0 0 (17,957) 111,890 471,704 2,971 12,825 708 10,562 (1,546,099) 7,402,147 8,948,246 0 0 39,325,859 (802) (7,809,887) (802) 0 31,893,743 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Minnesota DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.MN Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.MN 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.MN 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821625100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Mississippi DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.MS 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 58,913,777 58,913,777 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 58,913,777 (1,129,956) 58,913,777 (1,129,956) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,423 59,980,029 (11,917,859) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 54,675,486 (10,835,410) 0 0 43,840,076 0 0 443,250 443,250 0 0 0 0 159,464 602,714 0 0 0 0 0 443,250 0.919 443,250 XXX 159,464 XXX 602,714 XXX 0 0 0.000 988,613 988,613 0.016 0 988,613 988,613 XXX 382,713 382,713 XXX 0 1,371,326 1,371,326 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 53,281 0 XXX 0 0 0.000 0 48,062,170 XXX XXX XXX XXX XXX 53,281 0 10,423 59,980,029 (11,917,859) 0 0 48,062,170 (409,191) 123,738,590 68,658,034 (409,191) 123,738,590 68,658,034 XXX XXX XXX (409,191) 123,738,590 68,658,034 0 4,121 0 54,675,486 (10,835,410) 0 0 0 0 0 43,840,076 XXX XXX 0 4,121 0 54,675,486 (10,835,410) 0 0 0 0 0 43,840,076 4,121 0 58,913,777 (1,129,956) 53,281 0 10,423 59,980,029 (11,917,859) 0 0 48,062,170 XXX XXX XXX XXX 58,913,777 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 440 1,456,702 440 1,456,702 0 0 0 0 0 0 0 0 0 0 0 3,154,609 0 0 0 0 0 0 0 0 0 0 0 4,611,751 0 3,154,609 0 4,611,751 0 0 0 0 0 0 0 0 0 0 0 (1,821,520) (1,821,520) XXX 0 1,335,045 1,335,045 XXX 440 1,456,702 0 4,489,654 0 5,946,796 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (3,698,742) 1,946,057 232,293 XXX 232,293 XXX (1,589,227) 1,946,057 0 XXX (1,520,392) OTHER INDICATORS: 216-2.MS 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 100,876 100,876 2,800 103,676 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 100,876 100,876 2,800 103,676 3. Number of Groups 4. Member Months 34,444 1,230,089 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 1,195,645 1,195,645 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Mississippi DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.MS Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 58,945,001 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8,588 134,595 552,374 (417,779) 31,224 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 58,913,777 (1,310) (11,917,859) (1,310) 0 0 0 0 0 0 0 0 0 0 47,405,109 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 52,869,670 166,152 112,625 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8,588 134,595 552,374 4,121 17,804 982 14,665 (2,157,359) 10,269,712 12,427,071 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 54,675,486 (4,723) (10,835,410) (4,723) 0 0 0 0 0 0 0 0 0 0 44,249,267 58,945,001 0 0 0 8,588 134,595 552,374 (417,779) 31,224 0 58,913,777 (1,310) (11,917,859) (1,310) 0 47,405,109 52,869,670 166,152 112,625 0 0 0 0 8,588 134,595 552,374 4,121 17,804 982 14,665 (2,157,359) 10,269,712 12,427,071 0 0 54,675,486 (4,723) (10,835,410) (4,723) 0 44,249,267 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Mississippi DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.MS Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.MS 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.MS 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821626100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Missouri DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.MO 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 99,822,698 99,822,698 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 99,822,698 (1,216,253) 99,822,698 (1,216,253) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17,660 100,931,012 (20,214,142) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 91,175,419 (18,088,676) 0 0 73,086,743 0 0 751,037 751,037 0 0 0 0 270,193 1,021,230 0 0 0 0 0 751,037 0.911 751,037 XXX 270,193 XXX 1,021,230 XXX 0 0 0.000 1,675,093 1,675,093 0.017 0 1,675,093 1,675,093 XXX 648,463 648,463 XXX 0 2,323,556 2,323,556 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 90,279 0 XXX 0 0 0.000 0 80,716,870 XXX XXX XXX XXX XXX 90,279 0 17,660 100,931,012 (20,214,142) 0 0 80,716,870 (783,158) 206,569,689 114,617,992 (783,158) 206,569,689 114,617,992 XXX XXX XXX (783,158) 206,569,689 114,617,992 0 6,880 0 91,175,419 (18,088,676) 0 0 0 0 0 73,086,743 XXX XXX 0 6,880 0 91,175,419 (18,088,676) 0 0 0 0 0 73,086,743 6,880 0 99,822,698 (1,216,253) 90,279 0 17,660 100,931,012 (20,214,142) 0 0 80,716,870 XXX XXX XXX XXX 99,822,698 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 746 2,468,218 746 2,468,218 0 0 0 0 0 0 0 0 0 0 0 5,345,130 0 0 0 0 0 0 0 0 0 0 0 7,814,094 0 5,345,130 0 7,814,094 0 0 0 0 0 0 0 0 0 0 0 (2,610,097) (2,610,097) XXX 0 2,262,082 2,262,082 XXX 746 2,468,218 0 7,607,212 0 10,076,176 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (5,790,835) 3,297,371 386,427 XXX 386,427 XXX (2,223,670) 3,297,371 0 XXX (2,107,037) OTHER INDICATORS: 216-2.MO 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 148,896 148,896 6,781 155,677 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 148,896 148,896 6,781 155,677 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 1,777,073 82,749 1,859,822 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 1,777,073 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Missouri DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.MO Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 99,875,657 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (87,681) 228,290 923,767 (695,477) 52,959 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 99,822,698 (656) (20,214,142) (656) 0 0 0 0 0 0 0 0 0 0 80,391,714 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 87,550,853 277,375 194,511 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (87,681) 228,290 923,767 6,880 30,568 1,639 25,327 (4,317,980) 17,144,299 21,462,279 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 91,175,419 (3,238) (18,088,676) (3,238) 0 0 0 0 0 0 0 0 0 0 73,869,901 99,875,657 0 0 0 (87,681) 228,290 923,767 (695,477) 52,959 0 99,822,698 (656) (20,214,142) (656) 0 80,391,714 87,550,853 277,375 194,511 0 0 0 0 (87,681) 228,290 923,767 6,880 30,568 1,639 25,327 (4,317,980) 17,144,299 21,462,279 0 0 91,175,419 (3,238) (18,088,676) (3,238) 0 73,869,901 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Missouri DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.MO Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.MO 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.MO 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821627100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Montana DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.MT 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 13,695,823 13,695,823 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13,695,823 830,778 13,695,823 830,778 XXX 0 0 0 0 0 0 0 0 0 0 0 12,386 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,423 12,850,236 (2,771,912) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,125,717 (2,207,304) 0 0 8,918,413 0 0 103,043 103,043 0 0 0 0 37,071 140,114 0 0 0 0 0 103,043 0.874 103,043 XXX 37,071 XXX 140,114 XXX 0 0 0.000 229,825 229,825 0.018 0 229,825 229,825 XXX 88,970 88,970 XXX 0 318,795 318,795 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 10,078,324 XXX XXX XXX XXX XXX 12,386 0 2,423 12,850,236 (2,771,912) 0 0 10,078,324 (95,698) 25,207,046 13,986,471 (95,698) 25,207,046 13,986,471 XXX XXX XXX (95,698) 25,207,046 13,986,471 0 840 0 11,125,717 (2,207,304) 0 0 0 0 0 8,918,413 XXX XXX 0 840 0 11,125,717 (2,207,304) 0 0 0 0 0 8,918,413 840 0 13,695,823 830,778 12,386 0 2,423 12,850,236 (2,771,912) 0 0 10,078,324 XXX XXX XXX XXX 13,695,823 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 102 338,643 0 0 0 0 0 0 0 0 0 0 0 733,360 0 0 0 0 0 0 0 0 0 0 0 1,072,105 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 102 338,643 0 733,360 0 1,072,105 0 310,361 310,361 0 1,043,721 0 1,382,466 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (245,062) (245,062) XXX XXX 102 338,643 (681,464) 452,404 610,133 365,071 XXX 452,404 610,133 XXX 0 XXX 381,073 OTHER INDICATORS: 216-2.MT 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 21,427 21,427 920 22,347 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 21,427 21,427 920 22,347 3. Number of Groups 4. Member Months 11,101 264,385 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 253,284 253,284 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Montana DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.MT Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 13,703,085 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (4,625) 31,305 122,378 (91,073) 7,262 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13,695,823 (139) (2,771,912) (139) 0 0 0 0 0 0 0 0 0 0 11,019,609 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,863,581 33,847 22,087 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (4,625) 31,305 122,378 840 3,518 200 2,878 (345,234) 2,092,065 2,437,299 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,125,717 (547) (2,207,304) (547) 0 0 0 0 0 0 0 0 0 0 9,014,111 13,703,085 0 0 0 (4,625) 31,305 122,378 (91,073) 7,262 0 13,695,823 (139) (2,771,912) (139) 0 11,019,609 10,863,581 33,847 22,087 0 0 0 0 (4,625) 31,305 122,378 840 3,518 200 2,878 (345,234) 2,092,065 2,437,299 0 0 11,125,717 (547) (2,207,304) (547) 0 9,014,111 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Montana DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.MT Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.MT 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.MT 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821628100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Nebraska DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.NE 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 24,904,950 24,904,950 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24,904,950 28,990 24,904,950 28,990 XXX 0 0 0 0 0 0 0 0 0 0 0 22,524 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,406 24,849,030 (5,040,537) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23,294,955 (4,618,792) 0 0 18,676,163 0 0 187,377 187,377 0 0 0 0 67,411 254,788 0 0 0 0 0 187,377 0.945 187,377 XXX 67,411 XXX 254,788 XXX 0 0 0.000 417,922 417,922 0.017 0 417,922 417,922 XXX 161,786 161,786 XXX 0 579,708 579,708 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 19,808,493 XXX XXX XXX XXX XXX 22,524 0 4,406 24,849,030 (5,040,537) 0 0 19,808,493 (185,897) 52,745,839 29,266,744 (185,897) 52,745,839 29,266,744 XXX XXX XXX (185,897) 52,745,839 29,266,744 0 1,757 0 23,294,955 (4,618,792) 0 0 0 0 0 18,676,163 XXX XXX 0 1,757 0 23,294,955 (4,618,792) 0 0 0 0 0 18,676,163 1,757 0 24,904,950 28,990 22,524 0 4,406 24,849,030 (5,040,537) 0 0 19,808,493 XXX XXX XXX XXX 24,904,950 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 186 615,800 186 615,800 0 0 0 0 0 0 0 0 0 0 0 1,333,566 0 0 0 0 0 0 0 0 0 0 0 1,949,552 0 1,333,566 0 1,949,552 0 0 0 0 0 0 0 0 0 0 0 (1,422,521) (1,422,521) XXX 0 564,371 564,371 XXX 186 615,800 0 1,897,937 0 2,513,923 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (2,216,089) 822,667 1,091,044 XXX XXX (331,477) 822,667 1,091,044 0 XXX (302,378) OTHER INDICATORS: 216-2.NE 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 37,693 37,693 2,935 40,628 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 37,693 37,693 2,935 40,628 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 449,296 34,150 483,446 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 449,296 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Nebraska DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.NE Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 24,918,156 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (8,397) 56,926 234,426 (177,500) 13,206 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24,904,950 (246) (5,040,537) (246) 0 0 0 0 0 0 0 0 0 0 20,050,310 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 22,653,529 70,825 46,940 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (8,397) 56,926 234,426 1,757 7,450 419 6,112 (801,681) 4,377,653 5,179,334 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23,294,955 (922) (4,618,792) (922) 0 0 0 0 0 0 0 0 0 0 18,862,060 24,918,156 0 0 0 (8,397) 56,926 234,426 (177,500) 13,206 0 24,904,950 (246) (5,040,537) (246) 0 20,050,310 22,653,529 70,825 46,940 0 0 0 0 (8,397) 56,926 234,426 1,757 7,450 419 6,112 (801,681) 4,377,653 5,179,334 0 0 23,294,955 (922) (4,618,792) (922) 0 18,862,060 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Nebraska DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.NE Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.NE 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.NE 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821629100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Nevada DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.NV 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 11,097,895 11,097,895 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,097,895 819,232 11,097,895 819,232 XXX 0 0 0 0 0 0 0 0 0 0 0 10,037 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,963 10,266,663 (2,118,935) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 8,147,728 XXX XXX XXX XXX XXX 10,037 0 1,963 10,266,663 (2,118,935) 0 0 8,147,728 0 0 0 549,536 17,101,419 9,488,954 549,536 17,101,419 9,488,954 XXX XXX XXX 549,536 17,101,419 9,488,954 0 0 570 XXX XXX 0 0 0 0 8,162,571 (1,497,519) 0 0 6,665,052 0 570 0 8,162,571 (1,497,519) 0 0 0 0 0 6,665,052 0 570 0 8,162,571 (1,497,519) 0 0 0 0 0 6,665,052 0 0 83,495 83,495 0 0 0 0 30,039 113,534 0 0 0 0 0 83,495 0.803 83,495 XXX 30,039 XXX 113,534 XXX 0 0 0.000 186,225 186,225 0.018 0 186,225 186,225 XXX 72,094 72,094 XXX 0 258,319 258,319 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 11,097,895 819,232 10,037 0 1,963 10,266,663 (2,118,935) 0 0 8,147,728 XXX XXX XXX 0 11,097,895 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 83 274,398 83 274,398 0 0 0 0 0 0 0 0 0 0 0 594,232 0 0 0 0 0 0 0 0 0 0 0 868,713 0 594,232 0 868,713 0 0 0 0 0 0 0 0 0 0 0 344,243 344,243 0 251,489 251,489 0 845,721 0 1,120,202 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 83 274,398 (9,379) 366,589 49,680 393,923 XXX 366,589 49,680 XXX 0 XXX 406,890 OTHER INDICATORS: 216-2.NV 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 13,509 13,509 5,681 19,190 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 13,509 13,509 5,681 19,190 3. Number of Groups 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 160,752 160,752 68,742 229,494 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 1 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Nevada DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.NV Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 11,103,446 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 624,848 23,930 99,242 (75,312) 5,551 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,097,895 (875) (2,118,935) (875) 0 0 0 0 0 0 0 0 0 0 8,429,424 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,261,725 22,963 15,980 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 624,848 23,930 99,242 570 2,513 136 2,079 (343,757) 1,419,336 1,763,093 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8,162,571 (1,372) (1,497,519) (1,372) 0 0 0 0 0 0 0 0 0 0 6,115,516 11,103,446 0 0 0 624,848 23,930 99,242 (75,312) 5,551 0 11,097,895 (875) (2,118,935) (875) 0 8,429,424 7,261,725 22,963 15,980 0 0 0 0 624,848 23,930 99,242 570 2,513 136 2,079 (343,757) 1,419,336 1,763,093 0 0 8,162,571 (1,372) (1,497,519) (1,372) 0 6,115,516 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Nevada DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.NV Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.NV 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.NV 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821630100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF New Hampshire DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.NH 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 11,721,835 11,721,835 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,721,835 153,839 11,721,835 153,839 XXX 0 0 0 0 0 0 0 0 0 0 0 10,601 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,074 11,555,321 (2,251,194) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 9,304,127 XXX XXX XXX XXX XXX 10,601 0 2,074 11,555,321 (2,251,194) 0 0 9,304,127 0 0 0 524,718 21,495,946 11,927,317 524,718 21,495,946 11,927,317 XXX XXX XXX 524,718 21,495,946 11,927,317 0 0 716 XXX XXX 0 0 0 0 10,094,063 (1,882,334) 0 0 8,211,729 0 716 0 10,094,063 (1,882,334) 0 0 0 0 0 8,211,729 0 716 0 10,094,063 (1,882,334) 0 0 0 0 0 8,211,729 0 0 88,189 88,189 0 0 0 0 31,728 119,917 0 0 0 0 0 88,189 0.881 88,189 XXX 31,728 XXX 119,917 XXX 0 0 0.000 196,695 196,695 0.017 0 196,695 196,695 XXX 76,147 76,147 XXX 0 272,842 272,842 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 11,721,835 153,839 10,601 0 2,074 11,555,321 (2,251,194) 0 0 9,304,127 XXX XXX XXX 0 11,721,835 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 88 289,826 88 289,826 0 0 0 0 0 0 0 0 0 0 0 627,643 0 0 0 0 0 0 0 0 0 0 0 917,557 0 627,643 0 917,557 0 0 0 0 0 0 0 0 0 0 0 (110,043) (110,043) 0 265,628 265,628 0 893,271 0 1,183,185 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 88 289,826 (483,546) 387,199 48,203 XXX 48,203 XXX (61,840) 387,199 0 XXX (48,144) OTHER INDICATORS: 216-2.NH 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 17,325 17,325 6,833 24,158 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 17,325 17,325 6,833 24,158 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 206,138 80,093 286,231 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 206,138 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 New Hampshire DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.NH Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 11,727,733 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 595,086 25,424 95,792 (70,368) 5,898 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,721,835 (398) (2,251,194) (398) 0 0 0 0 0 0 0 0 0 0 8,945,923 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9,436,945 28,864 17,259 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 595,086 25,424 95,792 716 2,790 171 2,245 (120,079) 1,784,061 1,904,140 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,094,063 (2,126) (1,882,334) (2,126) 0 0 0 0 0 0 0 0 0 0 7,687,011 11,727,733 0 0 0 595,086 25,424 95,792 (70,368) 5,898 0 11,721,835 (398) (2,251,194) (398) 0 8,945,923 9,436,945 28,864 17,259 0 0 0 0 595,086 25,424 95,792 716 2,790 171 2,245 (120,079) 1,784,061 1,904,140 0 0 10,094,063 (2,126) (1,882,334) (2,126) 0 7,687,011 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF New Hampshire DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.NH Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.NH 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.NH 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821631100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF New Jersey DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.NJ 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 108,640,661 108,640,661 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 108,640,661 3,881,975 108,640,661 3,881,975 XXX 0 0 0 0 0 0 0 0 0 0 0 98,254 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19,221 104,641,211 (21,310,188) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 83,331,023 XXX XXX XXX XXX XXX 98,254 0 19,221 104,641,211 (21,310,188) 0 0 83,331,023 0 0 0 2,617,543 192,725,586 106,936,404 2,617,543 192,725,586 106,936,404 XXX XXX XXX 2,617,543 192,725,586 106,936,404 0 0 6,419 XXX XXX 0 0 0 0 88,413,144 (16,876,390) 0 0 71,536,754 0 6,419 0 88,413,144 (16,876,390) 0 0 0 0 0 71,536,754 0 6,419 0 88,413,144 (16,876,390) 0 0 0 0 0 71,536,754 0 0 817,367 817,367 0 0 0 0 294,061 1,111,428 0 0 0 0 0 817,367 0.853 817,367 XXX 294,061 XXX 1,111,428 XXX 0 0 0.000 1,823,034 1,823,034 0.017 0 1,823,034 1,823,034 XXX 705,746 705,746 XXX 0 2,528,780 2,528,780 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 108,640,661 3,881,975 98,254 0 19,221 104,641,211 (21,310,188) 0 0 83,331,023 XXX XXX XXX 0 108,640,661 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 812 2,686,207 812 2,686,207 0 0 0 0 0 0 0 0 0 0 0 5,817,202 0 0 0 0 0 0 0 0 0 0 0 8,504,221 0 5,817,202 0 8,504,221 0 0 0 0 0 0 0 0 0 0 0 649,647 649,647 0 2,461,906 2,461,906 0 8,279,108 0 10,966,127 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 812 2,686,207 (2,812,066) 3,588,649 427,108 1,076,755 XXX 3,588,649 427,108 XXX 0 XXX 1,203,691 OTHER INDICATORS: 216-2.NJ 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 134,945 134,945 19,168 154,113 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 134,945 134,945 19,168 154,113 3. Number of Groups 0 0 0 0 0 0 0 0 0 2 2 3 5 4. Member Months 0 0 0 0 0 0 0 0 0 1,608,369 1,608,369 226,156 1,834,525 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 New Jersey DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.NJ Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 108,696,491 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,312,966 240,668 936,091 (695,423) 55,830 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 108,640,661 (3,529) (21,310,188) (3,529) 0 0 0 0 0 0 0 0 0 0 84,712,930 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 81,665,149 258,786 181,637 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,312,966 240,668 936,091 6,419 28,545 1,529 23,655 (4,046,884) 15,995,304 20,042,188 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 88,413,144 (6,838) (16,876,390) (6,838) 0 0 0 0 0 0 0 0 0 0 68,919,211 108,696,491 0 0 0 3,312,966 240,668 936,091 (695,423) 55,830 0 108,640,661 (3,529) (21,310,188) (3,529) 0 84,712,930 81,665,149 258,786 181,637 0 0 0 0 3,312,966 240,668 936,091 6,419 28,545 1,529 23,655 (4,046,884) 15,995,304 20,042,188 0 0 88,413,144 (6,838) (16,876,390) (6,838) 0 68,919,211 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF New Jersey DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.NJ Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.NJ 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.NJ 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821632100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF New Mexico DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.NM 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 20,484,407 20,484,407 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20,484,407 1,934,510 20,484,407 1,934,510 XXX 0 0 0 0 0 0 0 0 0 0 0 18,526 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,624 18,527,747 (4,344,282) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14,162,230 (3,009,095) 0 0 11,153,135 0 0 154,123 154,123 0 0 0 0 55,446 209,569 0 0 0 0 0 154,123 0.773 154,123 XXX 55,446 XXX 209,569 XXX 0 0 0.000 343,751 343,751 0.019 0 343,751 343,751 XXX 133,070 133,070 XXX 0 476,821 476,821 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 14,183,465 XXX XXX XXX XXX XXX 18,526 0 3,624 18,527,747 (4,344,282) 0 0 14,183,465 (1,135,304) 34,363,371 19,066,982 (1,135,304) 34,363,371 19,066,982 XXX XXX XXX (1,135,304) 34,363,371 19,066,982 0 1,145 0 14,162,230 (3,009,095) 0 0 0 0 0 11,153,135 XXX XXX 0 1,145 0 14,162,230 (3,009,095) 0 0 0 0 0 11,153,135 1,145 0 20,484,407 1,934,510 18,526 0 3,624 18,527,747 (4,344,282) 0 0 14,183,465 XXX XXX XXX XXX 20,484,407 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 153 506,511 153 506,511 0 0 0 0 0 0 0 0 0 0 0 1,096,890 0 0 0 0 0 0 0 0 0 0 0 1,603,554 0 1,096,890 0 1,603,554 0 0 0 0 0 0 0 0 0 0 0 928,902 928,902 0 464,197 464,197 0 1,561,087 0 2,067,751 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 153 506,511 276,189 676,647 81,926 1,010,828 XXX 676,647 81,926 XXX 0 XXX 1,034,762 OTHER INDICATORS: 216-2.NM 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 38,520 38,520 2,530 41,050 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 38,520 38,520 2,530 41,050 3. Number of Groups 4. Member Months 30,375 489,820 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 459,445 459,445 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 New Mexico DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.NM Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 20,495,789 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (987,634) 49,062 196,732 (147,670) 11,382 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20,484,407 (757) (4,344,282) (757) 0 0 0 0 0 0 0 0 0 0 17,275,429 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14,561,616 46,142 32,379 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (987,634) 49,062 196,732 1,145 5,091 273 4,219 (721,010) 2,851,996 3,573,006 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14,162,230 (992) (3,009,095) (992) 0 0 0 0 0 0 0 0 0 0 12,288,439 20,495,789 0 0 0 (987,634) 49,062 196,732 (147,670) 11,382 0 20,484,407 (757) (4,344,282) (757) 0 17,275,429 14,561,616 46,142 32,379 0 0 0 0 (987,634) 49,062 196,732 1,145 5,091 273 4,219 (721,010) 2,851,996 3,573,006 0 0 14,162,230 (992) (3,009,095) (992) 0 12,288,439 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF New Mexico DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.NM Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.NM 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.NM 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821633100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF New York DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.NY 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 195,027,816 195,027,816 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 195,027,816 6,047,767 195,027,816 6,047,767 XXX 0 0 0 0 0 0 0 0 0 0 0 176,382 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 34,504 188,769,163 (40,907,170) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 160,580,722 (33,268,077) 0 0 127,312,645 0 0 1,467,360 1,467,360 0 0 0 0 527,888 1,995,248 0 0 0 0 0 1,467,360 0.858 1,467,360 XXX 527,888 XXX 1,995,248 XXX 0 0 0.000 3,272,761 3,272,761 0.017 0 3,272,761 3,272,761 XXX 1,266,930 1,266,930 XXX 0 4,539,691 4,539,691 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 147,861,993 XXX XXX XXX XXX XXX 176,382 0 34,504 188,769,163 (40,907,170) 0 0 147,861,993 (8,546,362) 379,915,939 210,801,509 (8,546,362) 379,915,939 210,801,509 XXX XXX XXX (8,546,362) 379,915,939 210,801,509 0 12,654 0 160,580,722 (33,268,077) 0 0 0 0 0 127,312,645 XXX XXX 0 12,654 0 160,580,722 (33,268,077) 0 0 0 0 0 127,312,645 12,654 0 195,027,816 6,047,767 176,382 0 34,504 188,769,163 (40,907,170) 0 0 147,861,993 XXX XXX XXX XXX 195,027,816 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,457 4,822,353 1,457 4,822,353 0 0 0 0 0 0 0 0 0 0 0 10,443,204 0 0 0 0 0 0 0 0 0 0 0 15,267,014 0 10,443,204 0 15,267,014 0 0 0 0 0 0 0 0 0 0 0 542,213 542,213 0 4,419,525 4,419,525 0 14,862,729 0 19,686,539 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 1,457 4,822,353 (5,672,130) 6,442,215 772,056 1,314,269 XXX 6,442,215 772,056 XXX 0 XXX 1,542,141 OTHER INDICATORS: 216-2.NY 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 248,333 248,333 252,159 500,492 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 248,333 248,333 252,159 500,492 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 11 11 4. Member Months 0 0 0 0 0 0 0 0 0 3,004,513 2,960,373 5,964,886 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 3,004,513 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 New York DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.NY Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 195,134,988 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (7,159,887) 461,988 1,848,463 (1,386,475) 107,172 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 195,027,816 (17,190) (40,907,170) (17,190) 0 0 0 0 0 0 0 0 0 0 162,667,008 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 159,984,565 510,139 367,210 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (7,159,887) 461,988 1,848,463 12,654 57,457 3,014 47,817 (8,986,936) 31,531,211 40,518,147 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 160,580,722 6,105 (33,268,077) 6,105 0 0 0 0 0 0 0 0 0 0 135,859,007 195,134,988 0 0 0 (7,159,887) 461,988 1,848,463 (1,386,475) 107,172 0 195,027,816 (17,190) (40,907,170) (17,190) 0 162,667,008 159,984,565 510,139 367,210 0 0 0 0 (7,159,887) 461,988 1,848,463 12,654 57,457 3,014 47,817 (8,986,936) 31,531,211 40,518,147 0 0 160,580,722 6,105 (33,268,077) 6,105 0 135,859,007 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF New York DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.NY Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.NY 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.NY 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821634100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF North Carolina DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.NC 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 127,624,435 127,624,435 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 127,624,435 3,042,470 127,624,435 3,042,470 XXX 0 0 0 0 0 0 0 0 0 0 0 115,423 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 22,579 124,443,963 (25,856,140) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 107,020,244 (21,262,238) 0 0 85,758,006 0 0 960,209 960,209 0 0 0 0 345,445 1,305,654 0 0 0 0 0 960,209 0.868 960,209 XXX 345,445 XXX 1,305,654 XXX 0 0 0.000 2,141,625 2,141,625 0.017 0 2,141,625 2,141,625 XXX 829,068 829,068 XXX 0 2,970,693 2,970,693 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 98,587,823 XXX XXX XXX XXX XXX 115,423 0 22,579 124,443,963 (25,856,140) 0 0 98,587,823 (1,071,976) 242,811,242 134,727,109 (1,071,976) 242,811,242 134,727,109 XXX XXX XXX (1,071,976) 242,811,242 134,727,109 0 8,087 0 107,020,244 (21,262,238) 0 0 0 0 0 85,758,006 XXX XXX 0 8,087 0 107,020,244 (21,262,238) 0 0 0 0 0 85,758,006 8,087 0 127,624,435 3,042,470 115,423 0 22,579 124,443,963 (25,856,140) 0 0 98,587,823 XXX XXX XXX XXX 127,624,435 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 953 3,155,645 0 0 0 0 0 0 0 0 0 0 0 6,833,810 0 0 0 0 0 0 0 0 0 0 0 9,990,408 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 953 3,155,645 0 6,833,810 0 9,990,408 0 2,892,097 2,892,097 0 9,725,907 0 12,882,505 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (262,425) (262,425) XXX XXX 953 3,155,645 (4,329,035) 4,215,727 507,740 245,315 XXX 4,215,727 507,740 XXX 0 XXX 394,432 OTHER INDICATORS: 216-2.NC 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 179,800 179,800 20,773 200,573 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 179,800 179,800 20,773 200,573 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 3 3 4. Member Months 0 0 0 0 0 0 0 0 0 2,173,293 245,550 2,418,843 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 2,173,293 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 North Carolina DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.NC Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 127,692,175 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (172,073) 292,008 1,191,911 (899,903) 67,740 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 127,624,435 (2,797) (25,856,140) (2,797) 0 0 0 0 0 0 0 0 0 0 102,840,271 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 101,999,745 326,039 236,971 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (172,073) 292,008 1,191,911 8,087 37,018 1,926 30,857 (5,995,320) 20,152,175 26,147,495 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 107,020,244 (8,524) (21,262,238) (8,524) 0 0 0 0 0 0 0 0 0 0 86,829,982 127,692,175 0 0 0 (172,073) 292,008 1,191,911 (899,903) 67,740 0 127,624,435 (2,797) (25,856,140) (2,797) 0 102,840,271 101,999,745 326,039 236,971 0 0 0 0 (172,073) 292,008 1,191,911 8,087 37,018 1,926 30,857 (5,995,320) 20,152,175 26,147,495 0 0 107,020,244 (8,524) (21,262,238) (8,524) 0 86,829,982 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF North Carolina DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.NC Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.NC 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.NC 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821635100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF North Dakota DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.ND 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 13,576,766 13,576,766 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13,576,766 339,879 13,576,766 339,879 XXX 0 0 0 0 0 0 0 0 0 0 0 12,279 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,402 13,222,206 (2,747,675) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,052,146 (2,389,798) 0 0 9,662,348 0 0 102,148 102,148 0 0 0 0 36,749 138,897 0 0 0 0 0 102,148 0.919 102,148 XXX 36,749 XXX 138,897 XXX 0 0 0.000 227,827 227,827 0.017 0 227,827 227,827 XXX 88,197 88,197 XXX 0 316,024 316,024 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 10,474,531 XXX XXX XXX XXX XXX 12,279 0 2,402 13,222,206 (2,747,675) 0 0 10,474,531 (97,026) 27,291,100 15,142,837 (97,026) 27,291,100 15,142,837 XXX XXX XXX (97,026) 27,291,100 15,142,837 0 909 0 12,052,146 (2,389,798) 0 0 0 0 0 9,662,348 XXX XXX 0 909 0 12,052,146 (2,389,798) 0 0 0 0 0 9,662,348 909 0 13,576,766 339,879 12,279 0 2,402 13,222,206 (2,747,675) 0 0 10,474,531 XXX XXX XXX XXX 13,576,766 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 101 335,699 0 0 0 0 0 0 0 0 0 0 0 726,985 0 0 0 0 0 0 0 0 0 0 0 1,062,785 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 101 335,699 0 726,985 0 1,062,785 0 307,663 307,663 0 1,034,648 0 1,370,448 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (580,577) (580,577) XXX XXX 101 335,699 (1,013,186) 448,472 617,568 36,991 XXX 448,472 617,568 XXX 0 XXX 52,854 OTHER INDICATORS: 216-2.ND 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 21,474 21,474 171 21,645 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 21,474 21,474 171 21,645 3. Number of Groups 4. Member Months 2,002 257,546 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 255,544 255,544 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 North Dakota DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.ND Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 13,583,965 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13,576,766 0 0 0 0 0 0 0 0 0 0 (2,747,675) 0 0 0 0 0 0 0 0 0 0 10,926,117 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,810,681 36,645 23,470 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (3,886) 31,031 124,171 909 3,746 217 3,054 (324,407) 2,265,031 2,589,438 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,052,146 (244) (2,389,798) (244) 0 0 0 0 0 0 0 0 0 0 9,759,374 0 (3,886) 31,031 124,171 (93,140) 7,199 13,583,965 0 0 0 (3,886) 31,031 124,171 (93,140) 7,199 0 13,576,766 0 (2,747,675) 0 0 10,926,117 11,810,681 36,645 23,470 0 0 0 0 (3,886) 31,031 124,171 909 3,746 217 3,054 (324,407) 2,265,031 2,589,438 0 0 12,052,146 (244) (2,389,798) (244) 0 9,759,374 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF North Dakota DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.ND Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.ND 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.ND 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821636100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Ohio DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.OH 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 122,982,155 122,982,155 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 122,982,155 955,969 122,982,155 955,969 XXX 0 0 0 0 0 0 0 0 0 0 0 111,224 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21,758 121,893,204 (24,750,722) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 107,258,165 (21,160,820) 0 0 86,097,345 0 0 925,278 925,278 0 0 0 0 332,880 1,258,158 0 0 0 0 0 925,278 0.888 925,278 XXX 332,880 XXX 1,258,158 XXX 0 0 0.000 2,063,717 2,063,717 0.017 0 2,063,717 2,063,717 XXX 798,911 798,911 XXX 0 2,862,628 2,862,628 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 97,142,482 XXX XXX XXX XXX XXX 111,224 0 21,758 121,893,204 (24,750,722) 0 0 97,142,482 (318,467) 241,653,058 134,084,475 (318,467) 241,653,058 134,084,475 XXX XXX XXX (318,467) 241,653,058 134,084,475 0 8,049 0 107,258,165 (21,160,820) 0 0 0 0 0 86,097,345 XXX XXX 0 8,049 0 107,258,165 (21,160,820) 0 0 0 0 0 86,097,345 8,049 0 122,982,155 955,969 111,224 0 21,758 121,893,204 (24,750,722) 0 0 97,142,482 XXX XXX XXX XXX 122,982,155 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 919 3,040,849 919 3,040,849 0 0 0 0 0 0 0 0 0 0 0 6,585,210 0 0 0 0 0 0 0 0 0 0 0 9,626,978 0 6,585,210 0 9,626,978 0 0 0 0 0 0 0 0 0 0 0 (1,570,836) (1,570,836) XXX 0 2,786,898 2,786,898 XXX 919 3,040,849 0 9,372,108 0 12,413,876 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (5,489,525) 4,062,382 479,981 XXX 479,981 XXX (1,090,855) 4,062,382 0 XXX (947,162) OTHER INDICATORS: 216-2.OH 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 195,618 195,618 31,570 227,188 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 195,618 195,618 31,570 227,188 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 5 5 4. Member Months 0 0 0 0 0 0 0 0 0 2,368,260 366,585 2,734,845 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 2,368,260 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Ohio DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.OH Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 123,046,999 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 649,282 279,524 1,247,273 (967,749) 64,844 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 122,982,155 (2,081) (24,750,722) (2,081) 0 0 0 0 0 0 0 0 0 0 98,549,900 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 102,282,137 324,484 228,806 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 649,282 279,524 1,247,273 8,049 35,929 1,917 29,797 (5,190,768) 20,056,051 25,246,819 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 107,258,165 (7,480) (21,160,820) (7,480) 0 0 0 0 0 0 0 0 0 0 86,415,812 123,046,999 0 0 0 649,282 279,524 1,247,273 (967,749) 64,844 0 122,982,155 (2,081) (24,750,722) (2,081) 0 98,549,900 102,282,137 324,484 228,806 0 0 0 0 649,282 279,524 1,247,273 8,049 35,929 1,917 29,797 (5,190,768) 20,056,051 25,246,819 0 0 107,258,165 (7,480) (21,160,820) (7,480) 0 86,415,812 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Ohio DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.OH Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.OH 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.OH 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821637100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Oklahoma DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.OK 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 57,011,180 57,011,180 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 57,011,180 (146,166) 57,011,180 (146,166) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,086 57,095,700 (11,587,800) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 50,927,344 (10,146,650) 0 0 40,780,694 0 0 428,936 428,936 0 0 0 0 154,314 583,250 0 0 0 0 0 428,936 0.899 428,936 XXX 154,314 XXX 583,250 XXX 0 0 0.000 956,688 956,688 0.017 0 956,688 956,688 XXX 370,353 370,353 XXX 0 1,327,041 1,327,041 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 51,560 0 XXX 0 0 0.000 0 45,507,900 XXX XXX XXX XXX XXX 51,560 0 10,086 57,095,700 (11,587,800) 0 0 45,507,900 (655,838) 115,873,062 64,293,739 (655,838) 115,873,062 64,293,739 XXX XXX XXX (655,838) 115,873,062 64,293,739 0 3,859 0 50,927,344 (10,146,650) 0 0 0 0 0 40,780,694 XXX XXX 0 3,859 0 50,927,344 (10,146,650) 0 0 0 0 0 40,780,694 3,859 0 57,011,180 (146,166) 51,560 0 10,086 57,095,700 (11,587,800) 0 0 45,507,900 XXX XXX XXX XXX 57,011,180 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 426 1,409,662 426 1,409,662 0 0 0 0 0 0 0 0 0 0 0 3,052,740 0 0 0 0 0 0 0 0 0 0 0 4,462,828 0 3,052,740 0 4,462,828 0 0 0 0 0 0 0 0 0 0 0 (1,121,246) (1,121,246) XXX 0 1,291,930 1,291,930 XXX 426 1,409,662 0 4,344,670 0 5,754,758 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (2,937,843) 1,883,209 219,681 XXX 219,681 XXX (901,565) 1,883,209 0 XXX (834,953) OTHER INDICATORS: 216-2.OK 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 85,205 85,205 37,418 122,623 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 85,205 85,205 37,418 122,623 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 1,012,824 449,295 1,462,119 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 1,012,824 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Oklahoma DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.OK Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 57,041,539 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (262,658) 130,867 524,047 (393,180) 30,359 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 57,011,180 (465) (11,587,800) (465) 0 0 0 0 0 0 0 0 0 0 46,079,218 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 49,923,628 155,591 101,674 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (262,658) 130,867 524,047 3,859 16,179 919 13,239 (1,601,778) 9,616,911 11,218,689 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 50,927,344 (2,222) (10,146,650) (2,222) 0 0 0 0 0 0 0 0 0 0 41,436,532 57,041,539 0 0 0 (262,658) 130,867 524,047 (393,180) 30,359 0 57,011,180 (465) (11,587,800) (465) 0 46,079,218 49,923,628 155,591 101,674 0 0 0 0 (262,658) 130,867 524,047 3,859 16,179 919 13,239 (1,601,778) 9,616,911 11,218,689 0 0 50,927,344 (2,222) (10,146,650) (2,222) 0 41,436,532 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Oklahoma DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.OK Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.OK 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.OK 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821638100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Oregon DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.OR 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 27,692,118 27,692,118 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27,692,118 2,559,429 27,692,118 2,559,429 XXX 0 0 0 0 0 0 0 0 0 0 0 25,045 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,899 25,102,745 (5,601,207) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19,266,714 (3,825,270) 0 0 15,441,444 0 0 208,347 208,347 0 0 0 0 74,955 283,302 0 0 0 0 0 208,347 0.776 208,347 XXX 74,955 XXX 283,302 XXX 0 0 0.000 464,692 464,692 0.019 0 464,692 464,692 XXX 179,892 179,892 XXX 0 644,584 644,584 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 19,501,538 XXX XXX XXX XXX XXX 25,045 0 4,899 25,102,745 (5,601,207) 0 0 19,501,538 (180,058) 43,683,947 24,238,630 (180,058) 43,683,947 24,238,630 XXX XXX XXX (180,058) 43,683,947 24,238,630 0 1,455 0 19,266,714 (3,825,270) 0 0 0 0 0 15,441,444 XXX XXX 0 1,455 0 19,266,714 (3,825,270) 0 0 0 0 0 15,441,444 1,455 0 27,692,118 2,559,429 25,045 0 4,899 25,102,745 (5,601,207) 0 0 19,501,538 XXX XXX XXX XXX 27,692,118 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 207 684,715 207 684,715 0 0 0 0 0 0 0 0 0 0 0 1,482,808 0 0 0 0 0 0 0 0 0 0 0 2,167,730 0 1,482,808 0 2,167,730 0 0 0 0 0 0 0 0 0 0 0 1,219,325 1,219,325 0 627,531 627,531 0 2,110,339 0 2,795,261 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 207 684,715 336,947 914,734 109,720 1,329,045 XXX 914,734 109,720 XXX 0 XXX 1,361,401 OTHER INDICATORS: 216-2.OR 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 39,374 39,374 3,331 42,705 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 39,374 39,374 3,331 42,705 3. Number of Groups 4. Member Months 40,208 504,061 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 463,853 463,853 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Oregon DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.OR Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 27,706,793 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,602 63,258 250,918 (187,660) 14,675 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27,692,118 (358) (5,601,207) (358) 0 0 0 0 0 0 0 0 0 0 22,270,969 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18,687,568 58,657 39,549 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,602 63,258 250,918 1,455 6,261 347 5,153 (738,641) 3,625,559 4,364,200 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19,266,714 (973) (3,825,270) (973) 0 0 0 0 0 0 0 0 0 0 15,621,502 27,706,793 0 0 0 7,602 63,258 250,918 (187,660) 14,675 0 27,692,118 (358) (5,601,207) (358) 0 22,270,969 18,687,568 58,657 39,549 0 0 0 0 7,602 63,258 250,918 1,455 6,261 347 5,153 (738,641) 3,625,559 4,364,200 0 0 19,266,714 (973) (3,825,270) (973) 0 15,621,502 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Oregon DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.OR Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.OR 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.OR 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821639100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Pennsylvania DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.PA 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 160,961,701 160,961,701 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 160,961,701 3,807,889 160,961,701 3,807,889 XXX 0 0 0 0 0 0 0 0 0 0 0 145,572 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 28,477 156,979,763 (32,550,259) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 134,984,163 (26,731,765) 0 0 108,252,398 0 0 1,211,028 1,211,028 0 0 0 0 435,680 1,646,708 0 0 0 0 0 1,211,028 0.868 1,211,028 XXX 435,680 XXX 1,646,708 XXX 0 0 0.000 2,701,044 2,701,044 0.017 0 2,701,044 2,701,044 XXX 1,045,632 1,045,632 XXX 0 3,746,676 3,746,676 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 124,429,504 XXX XXX XXX XXX XXX 145,572 0 28,477 156,979,763 (32,550,259) 0 0 124,429,504 (913,847) 305,272,336 169,384,494 (913,847) 305,272,336 169,384,494 XXX XXX XXX (913,847) 305,272,336 169,384,494 0 10,168 0 134,984,163 (26,731,765) 0 0 0 0 0 108,252,398 XXX XXX 0 10,168 0 134,984,163 (26,731,765) 0 0 0 0 0 108,252,398 10,168 0 160,961,701 3,807,889 145,572 0 28,477 156,979,763 (32,550,259) 0 0 124,429,504 XXX XXX XXX XXX 160,961,701 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,203 3,979,939 0 0 0 0 0 0 0 0 0 0 0 8,618,887 0 0 0 0 0 0 0 0 0 0 0 12,600,029 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 1,203 3,979,939 0 8,618,887 0 12,600,029 0 3,647,552 3,647,552 0 12,266,439 0 16,247,581 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (334,995) (334,995) XXX XXX 1,203 3,979,939 (5,463,859) 5,316,933 624,696 289,701 XXX 5,316,933 624,696 XXX 0 XXX 477,770 OTHER INDICATORS: 216-2.PA 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 225,681 225,681 101,061 326,742 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 225,681 225,681 101,061 326,742 3. Number of Groups 0 0 0 0 0 0 0 0 0 2 2 9 11 4. Member Months 0 0 0 0 0 0 0 0 0 2,713,741 2,713,741 1,105,926 3,819,667 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Pennsylvania DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.PA Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 161,046,979 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 78,851 367,608 1,360,306 (992,698) 85,278 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 160,961,701 (3,511) (32,550,259) (3,511) 0 0 0 0 0 0 0 0 0 0 129,325,289 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 131,972,543 409,909 263,778 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 78,851 367,608 1,360,306 10,168 42,093 2,422 34,347 (3,769,168) 25,336,148 29,105,316 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 134,984,163 (9,922) (26,731,765) (9,922) 0 0 0 0 0 0 0 0 0 0 109,166,245 161,046,979 0 0 0 78,851 367,608 1,360,306 (992,698) 85,278 0 160,961,701 (3,511) (32,550,259) (3,511) 0 129,325,289 131,972,543 409,909 263,778 0 0 0 0 78,851 367,608 1,360,306 10,168 42,093 2,422 34,347 (3,769,168) 25,336,148 29,105,316 0 0 134,984,163 (9,922) (26,731,765) (9,922) 0 109,166,245 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Pennsylvania DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.PA Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.PA 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.PA 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821640100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Rhode Island DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.RI 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 9,361,511 9,361,511 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9,361,511 603,035 9,361,511 603,035 XXX 0 0 0 0 0 0 0 0 0 0 0 8,466 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,656 8,748,354 (1,893,730) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,061,626 (1,402,443) 0 0 5,659,183 0 0 70,433 70,433 0 0 0 0 25,339 95,772 0 0 0 0 0 70,433 0.815 70,433 XXX 25,339 XXX 95,772 XXX 0 0 0.000 157,092 157,092 0.018 0 157,092 157,092 XXX 60,814 60,814 XXX 0 217,906 217,906 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 6,854,624 XXX XXX XXX XXX XXX 8,466 0 1,656 8,748,354 (1,893,730) 0 0 6,854,624 (68,064) 16,015,667 8,886,510 (68,064) 16,015,667 8,886,510 XXX XXX XXX (68,064) 16,015,667 8,886,510 0 533 0 7,061,626 (1,402,443) 0 0 0 0 0 5,659,183 XXX XXX 0 533 0 7,061,626 (1,402,443) 0 0 0 0 0 5,659,183 533 0 9,361,511 603,035 8,466 0 1,656 8,748,354 (1,893,730) 0 0 6,854,624 XXX XXX XXX XXX 9,361,511 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 70 231,473 70 231,473 0 0 0 0 0 0 0 0 0 0 0 501,273 0 0 0 0 0 0 0 0 0 0 0 732,816 0 501,273 0 732,816 0 0 0 0 0 0 0 0 0 0 0 235,100 235,100 0 212,141 212,141 0 713,414 0 944,957 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 70 231,473 (63,194) 309,232 38,063 273,163 XXX 309,232 38,063 XXX 0 XXX 284,101 OTHER INDICATORS: 216-2.RI 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 12,038 12,038 2,469 14,507 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 12,038 12,038 2,469 14,507 3. Number of Groups 4. Member Months 28,936 180,665 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 151,729 151,729 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Rhode Island DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.RI Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 9,366,472 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,564 21,387 91,015 (69,628) 4,961 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9,361,511 (806) (1,893,730) (806) 0 0 0 0 0 0 0 0 0 0 7,535,845 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6,633,649 21,505 16,489 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,564 21,387 91,015 533 2,556 127 2,150 (490,492) 1,329,224 1,819,716 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,061,626 (891) (1,402,443) (891) 0 0 0 0 0 0 0 0 0 0 5,727,247 9,366,472 0 0 0 1,564 21,387 91,015 (69,628) 4,961 0 9,361,511 (806) (1,893,730) (806) 0 7,535,845 6,633,649 21,505 16,489 0 0 0 0 1,564 21,387 91,015 533 2,556 127 2,150 (490,492) 1,329,224 1,819,716 0 0 7,061,626 (891) (1,402,443) (891) 0 5,727,247 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Rhode Island DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 216-4.RI 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.RI 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.RI 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821641100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF South Carolina DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.SC 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 56,746,976 56,746,976 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56,746,976 (1,407,416) 56,746,976 (1,407,416) XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,040 58,093,030 (11,464,298) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53,321,463 (10,544,108) 0 0 42,777,355 0 0 426,947 426,947 0 0 0 0 153,599 580,546 0 0 0 0 0 426,947 0.925 426,947 XXX 153,599 XXX 580,546 XXX 0 0 0.000 952,252 952,252 0.016 0 952,252 952,252 XXX 368,637 368,637 XXX 0 1,320,889 1,320,889 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 51,322 0 XXX 0 0 0.000 0 46,628,732 XXX XXX XXX XXX XXX 51,322 0 10,040 58,093,030 (11,464,298) 0 0 46,628,732 (282,303) 120,411,967 66,812,212 (282,303) 120,411,967 66,812,212 XXX XXX XXX (282,303) 120,411,967 66,812,212 0 4,011 0 53,321,463 (10,544,108) 0 0 0 0 0 42,777,355 XXX XXX 0 4,011 0 53,321,463 (10,544,108) 0 0 0 0 0 42,777,355 4,011 0 56,746,976 (1,407,416) 51,322 0 10,040 58,093,030 (11,464,298) 0 0 46,628,732 XXX XXX XXX XXX 56,746,976 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 424 1,403,125 424 1,403,125 0 0 0 0 0 0 0 0 0 0 0 3,038,583 0 0 0 0 0 0 0 0 0 0 0 4,442,132 0 3,038,583 0 4,442,132 0 0 0 0 0 0 0 0 0 0 0 (1,969,954) (1,969,954) XXX 0 1,285,943 1,285,943 XXX 424 1,403,125 0 4,324,526 0 5,728,075 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 1,874,483 224,879 XXX XXX (1,745,075) XXX (3,778,133) 1,874,483 224,879 0 (1,678,771) OTHER INDICATORS: 216-2.SC 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 97,384 97,384 12,277 109,661 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 97,384 97,384 12,277 109,661 3. Number of Groups 4. Member Months 145,428 1,299,921 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 1,154,493 1,154,493 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 South Carolina DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.SC Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 56,777,011 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 83,558 129,473 495,334 (365,861) 30,035 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56,746,976 (1,331) (11,464,298) (1,331) 0 0 0 0 0 0 0 0 0 0 45,564,981 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 52,039,075 161,686 104,192 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 83,558 129,473 495,334 4,011 16,626 955 13,570 (1,503,186) 9,993,619 11,496,805 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53,321,463 (4,501) (10,544,108) (4,501) 0 0 0 0 0 0 0 0 0 0 43,059,658 56,777,011 0 0 0 83,558 129,473 495,334 (365,861) 30,035 0 56,746,976 (1,331) (11,464,298) (1,331) 0 45,564,981 52,039,075 161,686 104,192 0 0 0 0 83,558 129,473 495,334 4,011 16,626 955 13,570 (1,503,186) 9,993,619 11,496,805 0 0 53,321,463 (4,501) (10,544,108) (4,501) 0 43,059,658 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF South Carolina DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.SC Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.SC 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.SC 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821642100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF South Dakota DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.SD 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 12,697,961 12,697,961 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,697,961 399,958 12,697,961 399,958 XXX 0 0 0 0 0 0 0 0 0 0 0 11,484 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,247 12,284,272 (2,569,876) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,061,460 (2,193,806) 0 0 8,867,654 0 0 95,536 95,536 0 0 0 0 34,370 129,906 0 0 0 0 0 95,536 0.908 95,536 XXX 34,370 XXX 129,906 XXX 0 0 0.000 213,080 213,080 0.017 0 213,080 213,080 XXX 82,488 82,488 XXX 0 295,568 295,568 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 9,714,396 XXX XXX XXX XXX XXX 11,484 0 2,247 12,284,272 (2,569,876) 0 0 9,714,396 (91,336) 25,052,907 13,900,945 (91,336) 25,052,907 13,900,945 XXX XXX XXX (91,336) 25,052,907 13,900,945 0 834 0 11,061,460 (2,193,806) 0 0 0 0 0 8,867,654 XXX XXX 0 834 0 11,061,460 (2,193,806) 0 0 0 0 0 8,867,654 834 0 12,697,961 399,958 11,484 0 2,247 12,284,272 (2,569,876) 0 0 9,714,396 XXX XXX XXX XXX 12,697,961 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 95 313,970 95 313,970 0 0 0 0 0 0 0 0 0 0 0 679,928 0 0 0 0 0 0 0 0 0 0 0 993,993 0 679,928 0 993,993 0 0 0 0 0 0 0 0 0 0 0 (455,867) (455,867) 0 287,748 287,748 0 967,676 0 1,281,741 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 95 313,970 (860,473) 419,442 545,600 89,733 XXX 419,442 545,600 XXX 0 XXX 104,569 OTHER INDICATORS: 216-2.SD 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 19,069 19,069 472 19,541 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 19,069 19,069 472 19,541 3. Number of Groups 4. Member Months 5,556 231,159 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 225,603 225,603 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 South Dakota DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.SD Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 12,704,694 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (3,902) 29,023 116,457 (87,434) 6,733 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,697,961 (98) (2,569,876) (98) 0 0 0 0 0 0 0 0 0 0 10,219,421 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,776,511 33,640 22,143 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (3,902) 29,023 116,457 834 3,518 199 2,883 (363,954) 2,079,272 2,443,226 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,061,460 (285) (2,193,806) (285) 0 0 0 0 0 0 0 0 0 0 8,958,990 12,704,694 0 0 0 (3,902) 29,023 116,457 (87,434) 6,733 0 12,697,961 (98) (2,569,876) (98) 0 10,219,421 10,776,511 33,640 22,143 0 0 0 0 (3,902) 29,023 116,457 834 3,518 199 2,883 (363,954) 2,079,272 2,443,226 0 0 11,061,460 (285) (2,193,806) (285) 0 8,958,990 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF South Dakota DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.SD Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.SD 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.SD 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821643100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Tennessee DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.TN 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 67,077,143 67,077,143 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 67,077,143 1,605,712 67,077,143 1,605,712 XXX 0 0 0 0 0 0 0 0 0 0 0 60,664 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,867 65,398,900 (13,567,881) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56,233,003 (11,148,985) 0 0 45,084,018 0 0 504,668 504,668 0 0 0 0 181,560 686,228 0 0 0 0 0 504,668 0.868 504,668 XXX 181,560 XXX 686,228 XXX 0 0 0.000 1,125,599 1,125,599 0.017 0 1,125,599 1,125,599 XXX 435,743 435,743 XXX 0 1,561,342 1,561,342 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 51,831,019 XXX XXX XXX XXX XXX 60,664 0 11,867 65,398,900 (13,567,881) 0 0 51,831,019 (445,817) 127,319,566 70,644,987 (445,817) 127,319,566 70,644,987 XXX XXX XXX (445,817) 127,319,566 70,644,987 0 4,241 0 56,233,003 (11,148,985) 0 0 0 0 0 45,084,018 XXX XXX 0 4,241 0 56,233,003 (11,148,985) 0 0 0 0 0 45,084,018 4,241 0 67,077,143 1,605,712 60,664 0 11,867 65,398,900 (13,567,881) 0 0 51,831,019 XXX XXX XXX XXX 67,077,143 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 501 1,658,550 0 0 0 0 0 0 0 0 0 0 0 3,591,726 0 0 0 0 0 0 0 0 0 0 0 5,250,777 0 0 0 0 0 0 0 0 0 0 0 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 501 1,658,550 0 3,591,726 0 5,250,777 0 1,520,035 1,520,035 0 5,111,761 0 6,770,812 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (134,043) (134,043) XXX XXX 501 1,658,550 (2,271,381) 2,215,711 267,438 133,395 XXX 2,215,711 267,438 XXX 0 XXX 211,768 OTHER INDICATORS: 216-2.TN 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 107,738 107,738 10,578 118,316 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 107,738 107,738 10,578 118,316 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 1,273,336 125,748 1,399,084 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 1,273,336 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Tennessee DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.TN Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 67,112,689 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16,561 153,230 615,608 (462,378) 35,546 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 67,077,143 (1,507) (13,567,881) (1,507) 0 0 0 0 0 0 0 0 0 0 53,955,079 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 54,359,978 170,961 116,248 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16,561 153,230 615,608 4,241 18,368 1,010 15,137 (2,259,888) 10,566,917 12,826,805 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56,233,003 (5,123) (11,148,985) (5,123) 0 0 0 0 0 0 0 0 0 0 45,529,835 67,112,689 0 0 0 16,561 153,230 615,608 (462,378) 35,546 0 67,077,143 (1,507) (13,567,881) (1,507) 0 53,955,079 54,359,978 170,961 116,248 0 0 0 0 16,561 153,230 615,608 4,241 18,368 1,010 15,137 (2,259,888) 10,566,917 12,826,805 0 0 56,233,003 (5,123) (11,148,985) (5,123) 0 45,529,835 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Tennessee DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.TN Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.TN 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.TN 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821644100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Texas DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.TX 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 174,345,072 174,345,072 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 174,345,072 2,680,921 174,345,072 2,680,921 XXX 0 0 0 0 0 0 0 0 0 0 0 157,676 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 30,845 171,475,630 (35,133,799) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 149,234,363 (29,427,751) 0 0 119,806,612 0 0 1,311,718 1,311,718 0 0 0 0 471,905 1,783,623 0 0 0 0 0 1,311,718 0.878 1,311,718 XXX 471,905 XXX 1,783,623 XXX 0 0 0.000 2,925,621 2,925,621 0.017 0 2,925,621 2,925,621 XXX 1,132,572 1,132,572 XXX 0 4,058,193 4,058,193 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 136,341,831 XXX XXX XXX XXX XXX 157,676 0 30,845 171,475,630 (35,133,799) 0 0 136,341,831 (369,402) 336,060,042 186,467,470 (369,402) 336,060,042 186,467,470 XXX XXX XXX (369,402) 336,060,042 186,467,470 0 11,193 0 149,234,363 (29,427,751) 0 0 0 0 0 119,806,612 XXX XXX 0 11,193 0 149,234,363 (29,427,751) 0 0 0 0 0 119,806,612 11,193 0 174,345,072 2,680,921 157,676 0 30,845 171,475,630 (35,133,799) 0 0 136,341,831 XXX XXX XXX XXX 174,345,072 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,303 4,310,849 1,303 4,310,849 0 0 0 0 0 0 0 0 0 0 0 9,335,499 0 0 0 0 0 0 0 0 0 0 0 13,647,651 0 9,335,499 0 13,647,651 0 0 0 0 0 0 0 0 0 0 0 (1,349,771) (1,349,771) XXX 0 3,950,833 3,950,833 XXX 1,303 4,310,849 0 13,286,332 0 17,598,484 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (6,905,081) 5,759,016 693,849 XXX 693,849 XXX (655,922) 5,759,016 0 XXX (452,216) OTHER INDICATORS: 216-2.TX 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 279,350 279,350 202,522 481,872 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 279,350 279,350 202,522 481,872 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 5 5 4. Member Months 0 0 0 0 0 0 0 0 0 3,263,697 2,295,354 5,559,051 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 3,263,697 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Texas DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.TX Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 174,437,119 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 692,825 396,786 1,459,013 (1,062,227) 92,047 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 174,345,072 (3,850) (35,133,799) (3,850) 0 0 0 0 0 0 0 0 0 0 139,580,675 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 142,599,758 451,250 314,915 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 692,825 396,786 1,459,013 11,193 49,534 2,666 41,007 (6,856,479) 27,891,381 34,747,860 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 149,234,363 (12,536) (29,427,751) (12,536) 0 0 0 0 0 0 0 0 0 0 120,176,014 174,437,119 0 0 0 692,825 396,786 1,459,013 (1,062,227) 92,047 0 174,345,072 (3,850) (35,133,799) (3,850) 0 139,580,675 142,599,758 451,250 314,915 0 0 0 0 692,825 396,786 1,459,013 11,193 49,534 2,666 41,007 (6,856,479) 27,891,381 34,747,860 0 0 149,234,363 (12,536) (29,427,751) (12,536) 0 120,176,014 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Texas DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.TX Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.TX 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.TX 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821645100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Utah DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.UT 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 12,057,925 12,057,925 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,057,925 464,362 12,057,925 464,362 XXX 0 0 0 0 0 0 0 0 0 0 0 10,905 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,133 11,580,525 (2,355,466) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 9,225,059 XXX XXX XXX XXX XXX 10,905 0 2,133 11,580,525 (2,355,466) 0 0 9,225,059 0 0 0 333,469 21,143,167 11,731,573 333,469 21,143,167 11,731,573 XXX XXX XXX 333,469 21,143,167 11,731,573 0 0 704 XXX XXX 0 0 0 0 9,745,767 (1,851,443) 0 0 7,894,324 0 704 0 9,745,767 (1,851,443) 0 0 0 0 0 7,894,324 0 704 0 9,745,767 (1,851,443) 0 0 0 0 0 7,894,324 0 0 90,719 90,719 0 0 0 0 32,638 123,357 0 0 0 0 0 90,719 0.849 90,719 XXX 32,638 XXX 123,357 XXX 0 0 0.000 202,336 202,336 0.017 0 202,336 202,336 XXX 78,330 78,330 XXX 0 280,666 280,666 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 12,057,925 464,362 10,905 0 2,133 11,580,525 (2,355,466) 0 0 9,225,059 XXX XXX XXX 0 12,057,925 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90 298,139 90 298,139 0 0 0 0 0 0 0 0 0 0 0 645,644 0 0 0 0 0 0 0 0 0 0 0 943,873 0 645,644 0 943,873 0 0 0 0 0 0 0 0 0 0 0 93,807 93,807 0 273,245 273,245 0 918,889 0 1,217,118 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 90 298,139 (290,406) 398,302 48,208 142,015 XXX 398,302 48,208 XXX 0 XXX 156,104 OTHER INDICATORS: 216-2.UT 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 17,138 17,138 1,448 18,586 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 17,138 17,138 1,448 18,586 3. Number of Groups 4. Member Months 17,184 218,620 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 201,436 201,436 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Utah DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.UT Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 12,064,096 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 415,803 26,602 108,936 (82,334) 6,171 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,057,925 (109) (2,355,466) (109) 0 0 0 0 0 0 0 0 0 0 9,368,990 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9,086,748 28,390 18,762 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 415,803 26,602 108,936 704 2,977 168 2,441 (315,218) 1,754,782 2,070,000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9,745,767 (550) (1,851,443) (550) 0 0 0 0 0 0 0 0 0 0 7,560,855 12,064,096 0 0 0 415,803 26,602 108,936 (82,334) 6,171 0 12,057,925 (109) (2,355,466) (109) 0 9,368,990 9,086,748 28,390 18,762 0 0 0 0 415,803 26,602 108,936 704 2,977 168 2,441 (315,218) 1,754,782 2,070,000 0 0 9,745,767 (550) (1,851,443) (550) 0 7,560,855 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Utah DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.UT Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.UT 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.UT 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821646100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Vermont DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.VT 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 12,529,546 12,529,546 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,529,546 418,237 12,529,546 418,237 XXX 0 0 0 0 0 0 0 0 0 0 0 11,332 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,217 12,097,760 (2,534,968) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,257,112 (2,035,145) 0 0 8,221,967 0 0 94,269 94,269 0 0 0 0 33,914 128,183 0 0 0 0 0 94,269 0.856 94,269 XXX 33,914 XXX 128,183 XXX 0 0 0.000 210,254 210,254 0.017 0 210,254 210,254 XXX 81,394 81,394 XXX 0 291,648 291,648 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 9,562,792 XXX XXX XXX XXX XXX 11,332 0 2,217 12,097,760 (2,534,968) 0 0 9,562,792 (89,089) 23,241,024 12,895,597 (89,089) 23,241,024 12,895,597 XXX XXX XXX (89,089) 23,241,024 12,895,597 0 774 0 10,257,112 (2,035,145) 0 0 0 0 0 8,221,967 XXX XXX 0 774 0 10,257,112 (2,035,145) 0 0 0 0 0 8,221,967 774 0 12,529,546 418,237 11,332 0 2,217 12,097,760 (2,534,968) 0 0 9,562,792 XXX XXX XXX XXX 12,529,546 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 94 309,806 94 309,806 0 0 0 0 0 0 0 0 0 0 0 670,910 0 0 0 0 0 0 0 0 0 0 0 980,810 0 670,910 0 980,810 0 0 0 0 0 0 0 0 0 0 0 55,492 55,492 0 283,932 283,932 0 954,842 0 1,264,742 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 94 309,806 (343,748) 413,880 48,893 104,385 XXX 413,880 48,893 XXX 0 XXX 119,025 OTHER INDICATORS: 216-2.VT 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 17,216 17,216 1,908 19,124 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 17,216 17,216 1,908 19,124 3. Number of Groups 4. Member Months 22,668 231,869 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 209,201 209,201 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Vermont DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.VT Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 12,536,187 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 216 28,629 117,934 (89,305) 6,641 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,529,546 (340) (2,534,968) (340) 0 0 0 0 0 0 0 0 0 0 10,083,667 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9,782,451 31,208 22,502 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 216 28,629 117,934 774 3,523 184 2,933 (554,270) 1,928,894 2,483,164 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,257,112 (460) (2,035,145) (460) 0 0 0 0 0 0 0 0 0 0 8,311,056 12,536,187 0 0 0 216 28,629 117,934 (89,305) 6,641 0 12,529,546 (340) (2,534,968) (340) 0 10,083,667 9,782,451 31,208 22,502 0 0 0 0 216 28,629 117,934 774 3,523 184 2,933 (554,270) 1,928,894 2,483,164 0 0 10,257,112 (460) (2,035,145) (460) 0 8,311,056 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Vermont DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.VT Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.VT 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.VT 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821647100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Virginia DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.VA 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 72,629,205 72,629,205 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 72,629,205 3,730,457 72,629,205 3,730,457 XXX 0 0 0 0 0 0 0 0 0 0 0 65,685 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,849 68,820,214 (14,430,857) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 54,389,357 XXX XXX XXX XXX XXX 65,685 0 12,849 68,820,214 (14,430,857) 0 0 54,389,357 0 0 0 820,237 133,987,701 74,344,892 820,237 133,987,701 74,344,892 XXX XXX XXX 820,237 133,987,701 74,344,892 0 0 4,463 XXX XXX 0 0 0 0 60,467,509 (11,732,894) 0 0 48,734,615 0 4,463 0 60,467,509 (11,732,894) 0 0 0 0 0 48,734,615 0 4,463 0 60,467,509 (11,732,894) 0 0 0 0 0 48,734,615 0 0 546,435 546,435 0 0 0 0 196,588 743,023 0 0 0 0 0 546,435 0.887 546,435 XXX 196,588 XXX 743,023 XXX 0 0 0.000 1,218,755 1,218,755 0.018 0 1,218,755 1,218,755 XXX 471,810 471,810 XXX 0 1,690,565 1,690,565 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 72,629,205 3,730,457 65,685 0 12,849 68,820,214 (14,430,857) 0 0 54,389,357 XXX XXX XXX 0 72,629,205 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 543 1,795,813 543 1,795,813 0 0 0 0 0 0 0 0 0 0 0 3,888,982 0 0 0 0 0 0 0 0 0 0 0 5,685,338 0 3,888,982 0 5,685,338 0 0 0 0 0 0 0 0 0 0 0 (1,795,786) (1,795,786) XXX 0 1,645,850 1,645,850 XXX 543 1,795,813 0 5,534,832 0 7,331,188 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 (4,110,034) 2,399,108 3,278,221 1,482,435 XXX 2,399,108 3,278,221 XXX 0 XXX 1,567,295 OTHER INDICATORS: 216-2.VA 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 113,408 113,408 21,454 134,862 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 113,408 113,408 21,454 134,862 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 2 2 4. Member Months 0 0 0 0 0 0 0 0 0 1,347,208 252,714 1,599,922 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 1,347,208 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Virginia DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.VA Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 72,667,012 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,303,276 162,976 646,015 (483,039) 37,807 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 72,629,205 (3,201) (14,430,857) (3,201) 0 0 0 0 0 0 0 0 0 0 57,378,111 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 57,744,298 179,914 117,419 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,303,276 162,976 646,015 4,463 18,693 1,063 15,293 (1,836,016) 11,120,340 12,956,356 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 60,467,509 (6,279) (11,732,894) (6,279) 0 0 0 0 0 0 0 0 0 0 47,914,378 72,667,012 0 0 0 1,303,276 162,976 646,015 (483,039) 37,807 0 72,629,205 (3,201) (14,430,857) (3,201) 0 57,378,111 57,744,298 179,914 117,419 0 0 0 0 1,303,276 162,976 646,015 4,463 18,693 1,063 15,293 (1,836,016) 11,120,340 12,956,356 0 0 60,467,509 (6,279) (11,732,894) (6,279) 0 47,914,378 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Virginia DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.VA Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.VA 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.VA 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821648100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Washington DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.WA 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 56,872,840 56,872,840 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56,872,840 4,751,149 56,872,840 4,751,149 XXX 0 0 0 0 0 0 0 0 0 0 0 51,435 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,062 52,060,194 (11,503,092) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40,623,046 (8,065,928) 0 0 32,557,118 0 0 427,894 427,894 0 0 0 0 153,939 581,833 0 0 0 0 0 427,894 0.789 427,894 XXX 153,939 XXX 581,833 XXX 0 0 0.000 954,364 954,364 0.018 0 954,364 954,364 XXX 369,455 369,455 XXX 0 1,323,819 1,323,819 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 40,557,102 XXX XXX XXX XXX XXX 51,435 0 10,062 52,060,194 (11,503,092) 0 0 40,557,102 (382,236) 92,111,564 51,109,350 (382,236) 92,111,564 51,109,350 XXX XXX XXX (382,236) 92,111,564 51,109,350 0 3,068 0 40,623,046 (8,065,928) 0 0 0 0 0 32,557,118 XXX XXX 0 3,068 0 40,623,046 (8,065,928) 0 0 0 0 0 32,557,118 3,068 0 56,872,840 4,751,149 51,435 0 10,062 52,060,194 (11,503,092) 0 0 40,557,102 XXX XXX XXX XXX 56,872,840 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 425 1,406,238 425 1,406,238 0 0 0 0 0 0 0 0 0 0 0 3,045,325 0 0 0 0 0 0 0 0 0 0 0 4,451,988 0 3,045,325 0 4,451,988 0 0 0 0 0 0 0 0 0 0 0 2,165,738 2,165,738 0 1,288,795 1,288,795 0 4,334,120 0 5,740,783 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 425 1,406,238 353,549 1,878,640 224,368 2,390,106 XXX 1,878,640 224,368 XXX 0 XXX 2,456,557 OTHER INDICATORS: 216-2.WA 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 78,917 78,917 5,797 84,714 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 78,917 78,917 5,797 84,714 3. Number of Groups 0 0 0 0 0 0 0 0 0 1 1 4. Member Months 0 0 0 0 0 0 0 0 0 951,545 951,545 69,775 1,021,320 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 1 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Washington DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.WA Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 56,902,977 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17,681 129,911 529,828 (399,917) 30,137 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56,872,840 (481) (11,503,092) (481) 0 0 0 0 0 0 0 0 0 0 45,751,984 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 39,004,385 123,684 87,059 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17,681 129,911 529,828 3,068 13,672 731 11,335 (1,961,204) 7,644,820 9,606,024 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40,623,046 (1,391) (8,065,928) (1,391) 0 0 0 0 0 0 0 0 0 0 32,939,354 56,902,977 0 0 0 17,681 129,911 529,828 (399,917) 30,137 0 56,872,840 (481) (11,503,092) (481) 0 45,751,984 39,004,385 123,684 87,059 0 0 0 0 17,681 129,911 529,828 3,068 13,672 731 11,335 (1,961,204) 7,644,820 9,606,024 0 0 40,623,046 (1,391) (8,065,928) (1,391) 0 32,939,354 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Washington DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.WA Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.WA 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.WA 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821649100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF West Virginia DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.WV 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 32,095,595 32,095,595 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 32,095,595 1,497,621 32,095,595 1,497,621 XXX 0 0 0 0 0 0 0 0 0 0 0 29,027 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,678 30,563,269 (6,489,125) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 25,386,715 (5,032,356) 0 0 20,354,359 0 0 241,478 241,478 0 0 0 0 86,874 328,352 0 0 0 0 0 241,478 0.839 241,478 XXX 86,874 XXX 328,352 XXX 0 0 0.000 538,585 538,585 0.018 0 538,585 538,585 XXX 208,498 208,498 XXX 0 747,083 747,083 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 24,074,144 XXX XXX XXX XXX XXX 29,027 0 5,678 30,563,269 (6,489,125) 0 0 24,074,144 (196,598) 57,468,669 31,887,270 (196,598) 57,468,669 31,887,270 XXX XXX XXX (196,598) 57,468,669 31,887,270 0 1,914 0 25,386,715 (5,032,356) 0 0 0 0 0 20,354,359 XXX XXX 0 1,914 0 25,386,715 (5,032,356) 0 0 0 0 0 20,354,359 1,914 0 32,095,595 1,497,621 29,027 0 5,678 30,563,269 (6,489,125) 0 0 24,074,144 XXX XXX XXX XXX 32,095,595 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 240 793,596 240 793,596 0 0 0 0 0 0 0 0 0 0 0 1,718,597 0 0 0 0 0 0 0 0 0 0 0 2,512,433 0 1,718,597 0 2,512,433 0 0 0 0 0 0 0 0 0 0 0 427,289 427,289 0 727,318 727,318 0 2,445,915 0 3,239,751 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 240 793,596 1,060,191 126,444 553,733 XXX (595,401) 1,060,191 126,444 XXX 0 XXX 591,234 OTHER INDICATORS: 216-2.WV 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 42,297 42,297 12,576 54,873 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 42,297 42,297 12,576 54,873 3. Number of Groups 4. Member Months 55,250 565,649 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 510,399 510,399 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 West Virginia DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.WV Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 32,112,596 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 22,457 73,285 292,340 (219,055) 17,001 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 32,095,595 (195) (6,489,125) (195) 0 0 0 0 0 0 0 0 0 0 25,803,068 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24,437,483 77,167 53,378 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 22,457 73,285 292,340 1,914 8,409 456 6,951 (1,120,127) 4,769,626 5,889,753 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 25,386,715 (1,901) (5,032,356) (1,901) 0 0 0 0 0 0 0 0 0 0 20,550,957 32,112,596 0 0 0 22,457 73,285 292,340 (219,055) 17,001 0 32,095,595 (195) (6,489,125) (195) 0 25,803,068 24,437,483 77,167 53,378 0 0 0 0 22,457 73,285 292,340 1,914 8,409 456 6,951 (1,120,127) 4,769,626 5,889,753 0 0 25,386,715 (1,901) (5,032,356) (1,901) 0 20,550,957 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF West Virginia DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.WV Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.WV 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.WV 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821650100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Wisconsin DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.WI 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 59,866,058 59,866,058 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 59,866,058 2,848,138 59,866,058 2,848,138 XXX 0 0 0 0 0 0 0 0 0 0 0 54,142 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,591 56,953,187 (11,860,316) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 45,092,871 XXX XXX XXX XXX XXX 54,142 0 10,591 56,953,187 (11,860,316) 0 0 45,092,871 0 0 0 821,783 104,304,749 57,874,904 821,783 104,304,749 57,874,904 XXX XXX XXX 821,783 104,304,749 57,874,904 0 0 3,474 0 0 0 0 47,255,102 (9,133,648) 0 0 38,121,454 0 0 450,409 450,409 0 0 0 0 162,041 612,450 0 0 0 0 0 450,409 0.838 450,409 XXX 162,041 XXX 612,450 XXX 0 0 0.000 1,004,581 1,004,581 0.018 0 1,004,581 1,004,581 XXX 388,899 388,899 XXX 0 1,393,480 1,393,480 XXX XXX XXX XXX 0 XXX XXX 0 0 0.000 0 3,474 0 47,255,102 (9,133,648) 0 0 0 0 0 38,121,454 0 59,866,058 2,848,138 54,142 0 10,591 56,953,187 (11,860,316) 0 0 45,092,871 XXX XXX XXX 0 59,866,058 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 3,474 0 47,255,102 (9,133,648) 0 0 0 0 0 38,121,454 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 447 1,480,232 447 1,480,232 0 0 0 0 0 0 0 0 0 0 0 3,205,565 0 0 0 0 0 0 0 0 0 0 0 4,686,244 0 3,205,565 0 4,686,244 0 0 0 0 0 0 0 0 0 0 0 830,183 830,183 0 1,356,625 1,356,625 0 4,562,190 0 6,042,869 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 447 1,480,232 (1,077,382) 1,977,513 239,416 1,069,599 XXX 1,977,513 239,416 XXX 0 XXX 1,139,547 OTHER INDICATORS: 216-2.WI 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 72,456 72,456 8,429 80,885 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 72,456 72,456 8,429 80,885 3. Number of Groups 0 0 0 0 0 0 0 0 0 0 3 3 4. Member Months 0 0 0 0 0 0 0 0 0 873,260 106,890 980,150 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 873,260 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Wisconsin DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.WI Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 59,897,131 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,245,281 133,945 557,443 (423,498) 31,073 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 59,866,058 (786) (11,860,316) (786) 0 0 0 0 0 0 0 0 0 0 47,183,959 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 44,199,575 140,056 98,286 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,245,281 133,945 557,443 3,474 15,448 828 12,802 (2,188,500) 8,656,797 10,845,297 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 47,255,102 (2,704) (9,133,648) (2,704) 0 0 0 0 0 0 0 0 0 0 37,299,671 59,897,131 0 0 0 1,245,281 133,945 557,443 (423,498) 31,073 0 59,866,058 (786) (11,860,316) (786) 0 47,183,959 44,199,575 140,056 98,286 0 0 0 0 1,245,281 133,945 557,443 3,474 15,448 828 12,802 (2,188,500) 8,656,797 10,845,297 0 0 47,255,102 (2,704) (9,133,648) (2,704) 0 37,299,671 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Wisconsin DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.WI Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.WI 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.WI 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821651100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Wyoming DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.WY 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 7,017,867 7,017,867 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,017,867 308,495 7,017,867 308,495 XXX 0 0 0 0 0 0 0 0 0 0 0 6,347 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,242 6,701,783 (1,420,312) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,957,105 (1,181,197) 0 0 4,775,908 0 0 52,800 52,800 0 0 0 0 18,995 71,795 0 0 0 0 0 52,800 0.897 52,800 XXX 18,995 XXX 71,795 XXX 0 0 0.000 117,765 117,765 0.018 0 117,765 117,765 XXX 45,589 45,589 XXX 0 163,354 163,354 XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 XXX 0 0 0.000 0 5,281,471 XXX XXX XXX XXX XXX 6,347 0 1,242 6,701,783 (1,420,312) 0 0 5,281,471 (47,822) 13,489,073 7,484,595 (47,822) 13,489,073 7,484,595 XXX XXX XXX (47,822) 13,489,073 7,484,595 0 449 0 5,957,105 (1,181,197) 0 0 0 0 0 4,775,908 XXX XXX 0 449 0 5,957,105 (1,181,197) 0 0 0 0 0 4,775,908 449 0 7,017,867 308,495 6,347 0 1,242 6,701,783 (1,420,312) 0 0 5,281,471 XXX XXX XXX XXX 7,017,867 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 52 173,524 52 173,524 0 0 0 0 0 0 0 0 0 0 0 375,780 0 0 0 0 0 0 0 0 0 0 0 549,356 0 375,780 0 549,356 0 0 0 0 0 0 0 0 0 0 0 (214,358) (214,358) 0 159,032 159,032 0 534,812 0 708,388 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 52 173,524 (437,974) 231,816 322,693 108,335 XXX 231,816 322,693 XXX 0 XXX 116,535 OTHER INDICATORS: 216-2.WY 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 11,627 11,627 567 12,194 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 11,627 11,627 567 12,194 3. Number of Groups 4. Member Months 6,841 143,226 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 136,385 136,385 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Wyoming DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.WY Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 7,021,588 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (2,164) 16,040 61,698 (45,658) 3,721 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,017,867 (220) (1,420,312) (220) 0 0 0 0 0 0 0 0 0 0 5,645,377 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,847,944 18,113 11,506 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (2,164) 16,040 61,698 449 1,839 107 1,497 (149,927) 1,119,529 1,269,456 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,957,105 (187) (1,181,197) (187) 0 0 0 0 0 0 0 0 0 0 4,823,730 7,021,588 0 0 0 (2,164) 16,040 61,698 (45,658) 3,721 0 7,017,867 (220) (1,420,312) (220) 0 5,645,377 5,847,944 18,113 11,506 0 0 0 0 (2,164) 16,040 61,698 449 1,839 107 1,497 (149,927) 1,119,529 1,269,456 0 0 5,957,105 (187) (1,181,197) (187) 0 4,823,730 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Wyoming DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.WY Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.WY 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.WY 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821652100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF American Samoa DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.AS 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 0 3 Large Group Employer 0 4 5 Small Group Employer Individual 0 0 Expatriate Plans 6 Large Group Employer 0 7 0 Student Health Plans Large Group 0 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 XXX XXX XXX 0 12575 13 0 0 0 XXX XXX XXX 0 0 0 0 0 XXX 0 0 0 0 0 0 0 0 0 0 XXX XXX XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 XXX XXX 0 0 0 0 0 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 XXX 0 XXX 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0 0 0 0 XXX 0 XXX 0 0 0 XXX 0 XXX 0 0 0 0 XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 0 0 0 0 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 0 0 0 0 0 0 0 0 0 0 0 0 0 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 0 XXX XXX 0 0 0 OTHER INDICATORS: 216-2.AS 1. Number of certificates/policies 0 0 2. Number of Covered Lives 0 0 3. Number of Groups 0 0 4. Member Months 0 0 XXX Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ XXX ] If yes, show the amount of premiums and claims included. Premiums $ Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 American Samoa DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.AS Health Premiums Earned: 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 1.5 Paid rate credits 1.6 Reserve for rate credits current year 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 1.12 Assumed premiums earned from non-affiliates 1.13 Net Assumed less Ceded premiums earned from affiliates 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 2.1 Paid claims during the year 2.2 Direct claim liability current year 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 2.8 Paid rate credits 2.9 Reserve for rate credits current year 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 2.11a Paid medical incentive pools and bonuses current year 2.11b Accrued medical incentive pools and bonuses current year 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 2.12a Healthcare receivables current year 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 2.16 Assumed incurred claims from non-affiliates 2.17 Net assumed less ceded incurred claims from affiliates 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF American Samoa DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.AS Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.AS 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.AS 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821653100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Guam DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.GU 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 14,166 14,166 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14,166 5,091 14,166 5,091 XXX 0 0 0 0 0 0 0 0 0 0 0 13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 9,059 (2,866) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 6,193 XXX XXX XXX XXX XXX 13 0 3 9,059 (2,866) 0 0 6,193 0 0 4,511 2,503 0 4,511 2,503 XXX XXX XXX 0 4,511 2,503 0 0 0 XXX XXX 0 0 0 0 2,008 (395) 0 0 1,613 0 0 0 2,008 (395) 0 0 0 0 0 1,613 0 0 0 2,008 (395) 0 0 0 0 0 1,613 0 0 107 0 107 0.233 XXX XXX XXX 0 XXX XXX 0 0 0.000 0 0 0.000 238 238 0.026 0 14,166 5,091 13 0 3 9,059 (2,866) 0 0 6,193 XXX XXX XXX 0 14,166 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX 107 0 0 0 0 38 107 XXX 38 XXX 0 238 238 XXX 145 0 0 0 0 145 XXX 0 330 330 92 92 XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 350 0 0 0 0 0 0 0 0 0 0 0 350 0 0 0 0 0 0 0 0 0 0 0 759 0 0 0 0 0 0 0 0 0 0 0 1,109 0 759 0 1,109 0 0 0 0 0 0 0 0 0 0 0 3,126 3,126 0 321 321 XXX 0 350 0 1,080 0 1,430 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX 2,675 468 95 3,221 XXX 468 95 XXX 0 XXX 3,238 OTHER INDICATORS: 216-2.GU 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 21 21 2 23 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 21 21 2 23 3. Number of Groups 4. Member Months 25 250 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 225 225 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Guam DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.GU Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 1.5 Paid rate credits 1.6 Reserve for rate credits current year 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 2.8 Paid rate credits 2.9 Reserve for rate credits current year 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 2.11a Paid medical incentive pools and bonuses current year 2.11b Accrued medical incentive pools and bonuses current year 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 14,174 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8 0 0 0 0 0 0 0 0 0 0 14,166 0 0 0 0 0 0 0 0 0 0 (2,866) 0 0 0 0 0 0 0 0 0 0 11,300 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,039 6 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 33 375 342 0 0 0 0 0 0 0 0 0 0 2,008 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (395) 1,613 14,174 0 0 0 0 0 0 0 8 0 14,166 0 (2,866) 0 0 11,300 2,039 6 4 0 0 0 0 0 0 0 0 0 0 0 33 375 342 0 0 2,008 0 (395) 0 0 1,613 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Guam DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.GU Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.GU 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.GU 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821654100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Puerto Rico DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.PR 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 372,229 372,229 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 372,229 133,525 372,229 133,525 XXX 0 0 0 0 0 0 0 0 0 0 0 337 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 66 238,301 (75,310) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 162,991 XXX XXX XXX XXX XXX 337 0 66 238,301 (75,310) 0 0 162,991 0 0 136,954 75,991 0 136,954 75,991 XXX XXX XXX 0 136,954 75,991 0 0 5 XXX XXX 0 0 0 0 60,968 (11,993) 0 0 48,975 0 5 0 60,968 (11,993) 0 0 0 0 0 48,975 0 5 0 60,968 (11,993) 0 0 0 0 0 48,975 0 0 2,801 0 2,801 0.268 XXX XXX XXX 0 XXX XXX 0 0 0.000 0 0 0.000 6,246 6,246 0.026 0 372,229 133,525 337 0 66 238,301 (75,310) 0 0 162,991 XXX XXX XXX 0 372,229 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX 2,801 0 0 0 0 1,008 2,801 XXX 1,008 XXX 0 6,246 6,246 XXX 3,809 0 0 0 0 3,809 XXX 0 8,664 8,664 2,418 2,418 XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3 9,204 3 9,204 0 0 0 0 0 0 0 0 0 0 0 19,931 0 0 0 0 0 0 0 0 0 0 0 29,138 0 19,931 0 29,138 0 0 0 0 0 0 0 0 0 0 0 75,831 75,831 0 8,435 8,435 0 28,366 0 37,573 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX XXX 3 9,204 63,970 12,296 8,617 84,448 XXX 12,296 8,617 XXX 0 XXX 84,883 OTHER INDICATORS: 216-2.PR 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 477 477 2,194 2,671 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 477 477 2,194 2,671 3. Number of Groups 4. Member Months 26,944 32,917 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 5,973 5,973 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Puerto Rico DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.PR Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 1.5 Paid rate credits 1.6 Reserve for rate credits current year 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 2.8 Paid rate credits 2.9 Reserve for rate credits current year 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 372,426 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 197 0 0 0 0 0 0 0 0 0 0 372,229 0 0 0 0 0 0 0 0 0 0 (75,310) 0 0 0 0 0 0 0 0 0 0 296,919 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 57,610 184 135 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5 19 1 15 (3,304) 11,366 14,670 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 60,968 (2) (11,993) (2) 0 0 0 0 0 0 0 0 0 0 48,975 372,426 0 0 0 0 0 0 0 197 0 372,229 0 (75,310) 0 0 296,919 57,610 184 135 0 0 0 0 0 0 0 5 19 1 15 (3,304) 11,366 14,670 0 0 60,968 (2) (11,993) (2) 0 48,975 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Puerto Rico DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.PR Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.PR 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.PR 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821655100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF U.S. Virgin Islands DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.VI 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 40,330 40,330 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40,330 8,967 40,330 8,967 XXX 0 0 0 0 0 0 0 0 0 0 0 36 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 31,320 (8,160) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 23,160 XXX XXX XXX XXX XXX 36 0 7 31,320 (8,160) 0 0 23,160 0 0 40,731 22,600 0 40,731 22,600 XXX XXX XXX 0 40,731 22,600 0 0 1 XXX XXX 0 0 0 0 18,132 (3,567) 0 0 14,565 0 1 0 18,132 (3,567) 0 0 0 0 0 14,565 0 1 0 18,132 (3,567) 0 0 0 0 0 14,565 0 0 303 0 303 0.589 XXX XXX XXX 0 XXX XXX 0 0 0.000 0 0 0.000 677 677 0.022 0 40,330 8,967 36 0 7 31,320 (8,160) 0 0 23,160 XXX XXX XXX 0 40,330 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX 303 0 0 0 0 109 303 XXX 109 XXX 0 677 677 XXX 412 0 0 0 0 412 XXX 0 939 939 262 262 XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 997 0 0 0 0 0 0 0 0 0 0 0 997 0 0 0 0 0 0 0 0 0 0 0 2,159 0 0 0 0 0 0 0 0 0 0 0 3,156 0 2,159 0 3,156 0 0 0 0 0 0 0 0 0 0 0 4,459 4,459 0 914 914 XXX 0 997 0 3,073 0 4,070 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX 3,174 1,332 997 5,456 XXX 1,332 997 XXX 0 XXX 5,503 OTHER INDICATORS: 216-2.VI 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 54 54 34 88 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 54 54 34 88 3. Number of Groups 4. Member Months 443 1,120 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 677 677 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 U.S. Virgin Islands DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.VI Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 1.5 Paid rate credits 1.6 Reserve for rate credits current year 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 2.8 Paid rate credits 2.9 Reserve for rate credits current year 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 40,351 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21 0 0 0 0 0 0 0 0 0 0 40,330 0 0 0 0 0 0 0 0 0 0 (8,160) 0 0 0 0 0 0 0 0 0 0 32,170 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17,525 55 36 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18,132 0 0 0 0 0 0 0 0 0 0 (3,567) 0 0 0 0 0 0 0 0 0 0 14,565 5 (587) 3,380 3,967 40,351 0 0 0 0 0 0 0 21 0 40,330 0 (8,160) 0 0 32,170 17,525 55 36 0 0 0 0 0 0 0 1 6 0 5 (587) 3,380 3,967 0 0 18,132 0 (3,567) 0 0 14,565 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF U.S. Virgin Islands DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 216-4.VI 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.VI 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.VI 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821656100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Northern Mariana Islands DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.MP 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 705 705 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 705 301 705 301 XXX 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 403 (143) 0 0 0 0 0 0 0 0 0 0 0 260 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (2) (1) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (1) 0 0 0 (1) 0 0 5 0 5 0.010 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 0 0 0.000 XXX XXX XXX 0 XXX XXX 0 0 0.000 0 0 0.000 12 12 0.030 705 301 0 1 0 0 403 (143) 0 0 260 0 XXX XXX XXX XXX XXX 1 0 0 403 (143) 0 0 260 0 (2) (1) XXX XXX XXX 0 (2) (1) 0 0 0 (1) 0 0 0 0 0 0 (1) XXX XXX 0 0 0 (1) 0 0 0 0 0 0 (1) XXX XXX XXX XXX XXX XXX XXX XXX 5 0 0 0 0 2 5 XXX 7 0 0 0 0 2 XXX 0 12 12 XXX 705 0 0 7 XXX 0 17 17 5 5 XXX XXX SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 17 0 0 0 0 0 0 0 0 0 0 0 17 0 0 0 0 0 0 0 0 0 0 0 38 0 0 0 0 0 0 0 0 0 0 0 55 0 38 0 55 0 0 0 0 0 0 0 0 0 0 0 189 189 0 16 16 XXX 0 17 0 54 0 71 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 XXX 166 24 3 192 24 XXX 3 XXX 0 XXX 193 OTHER INDICATORS: 216-2.MP 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 3. Number of Groups 4. Member Months 0 13 XXX XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ 0 0 ] If yes, show the amount of premiums and claims included. Premiums $ 0 0 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 0 0 0 0 13 13 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Northern Mariana Islands DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.MP Health Premiums Earned: 0 1.1 Direct premiums written 1.2 Unearned premium prior year 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 1.5 Paid rate credits 1.6 Reserve for rate credits current year 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 1.9 Premium balances written off 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 1.14 Ceded premiums earned to non-affiliates 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 2.4 Direct claim reserves current year 2.5 Direct claim reserves prior year 2.6 Direct contract reserves current year 2.7 Direct contract reserves prior year 2.8 Paid rate credits 2.9 Reserve for rate credits current year 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 2.11a Paid medical incentive pools and bonuses current year 2.11b Accrued medical incentive pools and bonuses current year 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 2.13 Group conversion charge 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 2.16 Assumed incurred claims from non-affiliates 2.17 Net assumed less ceded incurred claims from affiliates 2.18 Ceded incurred claims to non-affiliates 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above (informational only) (a) Column 13, Line 1.1 includes direct written premium of $ for stand-alone dental and $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 705 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 705 0 0 0 0 0 0 0 0 0 0 (143) 0 0 0 0 0 0 0 0 0 0 562 0 0 0 0 0 0 0 0 0 0 (68) 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (68) 0 0 0 0 0 0 0 0 0 0 68 0 0 0 0 0 0 0 0 0 0 (1) 0 0 0 0 0 0 0 0 0 0 (1) 705 0 0 0 0 0 0 0 0 0 705 0 (143) 0 0 562 (68) 0 1 0 0 0 0 0 0 0 0 0 0 0 (68) 0 68 0 0 (1) 0 0 0 0 (1) 0 for stand-alone vision policies. SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Northern Mariana Islands DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.MP Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.MP 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.MP 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201821659100* SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes - See Cautionary Statement at http://www.naic.org/documents/committees_e_app_blanks_related_shce_cautionary_statement.pdf) SilverScript Insurance Company 2. 445 Great Circle Road Nashville, TN 37228 (LOCATION) BUSINESS IN THE STATE OF Grand Total DURING THE YEAR 2018 NAIC Company Code Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 1. 216-1.GT 2. 3. 4. 5. 6. 7. 8. 9. Premium: 1.1 Health premiums earned (From Part 2, Line 1.11) 1.2 Federal high risk pools 1.3 State high risk pools 1.4 Premiums earned including state and federal high risk programs (Lines 1.1 + 1.2 + 1.3) 1.5 Federal taxes and federal assessments 1.6 State insurance, premium and other taxes (Similar local taxes of 0 ) $ 1.6a Community Benefit Expenditures (informational only) 1.7 Regulatory authority licenses and fees 1.8 Adjusted Premiums Earned (Lines 1.4 - 1.5 - 1.6 - 1.7) 1.9 Net Assumed less Ceded reinsurance premiums earned 1.10 Other Adjustments due to MLR calculations - Premiums 1.11 Risk Revenue 1.12 Net adjusted premiums earned after reinsurance (Lines 1.8 + 1.9 + 1.10 + 1.11) Claims: 2.1 Incurred claims excluding prescription drugs 2.2 Prescription drugs 2.3 Pharmaceutical rebates 2.4 State stop loss, market stabilization and claim/census based assessments (informational only) Incurred medical incentive pools and bonuses Deductible Fraud and Abuse Detection/Recovery Expenses (for MLR use only) 5.0 Total Incurred Claims (Lines 2.1 + 2.2 - 2.3 + 3) (From Part 2, Line 2.15) 5.1 Net Assumed less Ceded reinsurance claims incurred 5.2 Other Adjustments due to MLR calculations - Claims 5.3 Rebates paid 5.4 Estimated rebates unpaid prior year 5.5 Estimated rebates unpaid current year 5.6 Fee for service and co-pay revenue 5.7 Net incurred claims after reinsurance (Lines 5.0 + 5.1 + 5.2 + 5.3 - 5.4 + 5.5 - 5.6) Improving Health Care Quality Expenses Incurred: 6.1 Improve health outcomes 6.2 Activities to prevent hospital readmissions 6.3 Improve patient safety and reduce medical errors 6.4 Wellness and health promotion activities 6.5 Health Information Technology expenses related to health improvement 6.6 Total of Defined Expenses Incurred for Improving Health Care Quality (Lines 6.1+6.2+6.3+6.4+6.5) Preliminary Medical Loss Ratio: MLR ((Lines 4 + 5.0 + 6.6 - Footnote 2.0)/Line 1.8 Claims Adjustment Expenses: 8.1 Cost containment expenses not included in quality of care expenses in Line 6.6 8.2 All other claims adjustment expenses 8.3 Total claims adjustment expenses (Lines 8.1 + 8.2) Claims Adjustment Expense Ratio (Line 8.3/Line 1.8) 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 8 Small Group 10 Student Health Plans Large Group 12575 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,346,342,827 0 0 3,346,342,827 0 0 XXX XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,346,342,827 106,452,090 3,346,342,827 106,452,090 XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,026,406 0 592,030 3,236,272,301 (677,172,865) 0 0 2,559,099,436 3,026,406 0 592,030 3,236,272,301 (677,172,865) 0 0 2,559,099,436 XXX XXX XXX XXX XXX 3,026,406 0 592,030 3,236,272,301 (677,172,865) 0 0 2,559,099,436 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (22,168,128) 6,301,923,876 3,496,707,890 (22,168,128) 6,301,923,876 3,496,707,890 XXX XXX XXX (22,168,128) 6,301,923,876 3,496,707,890 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 209,901 0 2,783,257,759 (551,840,212) 0 0 0 0 0 2,231,417,547 0 209,901 0 2,783,257,759 (551,840,212) 0 0 0 0 0 2,231,417,547 XXX XXX 0 209,901 0 2,783,257,759 (551,840,212) 0 0 0 0 0 2,231,417,547 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0.000 0 0 0 0.000 0 0 0 0.000 0 0 0 0.000 0 0 0 0.000 0 0 0 0.000 0 0 0 0.000 0 0 0 0.000 0 0 0 0.000 0 0 0 0.000 XXX XXX XXX XXX XXX XXX 3,346,342,827 0 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX 3,346,342,827 106,452,090 0 0 0 0 0 0 0 0 0 0 0 0 0 0 25,176,889 0 0 0 0 25,176,889 0 0 0 0 9,057,647 0 0 0 0 34,234,536 0 0 0 0 0 25,176,889 0.868 25,176,889 XXX 9,057,647 XXX 34,234,536 XXX 0 0 0 0.000 0 56,153,880 56,153,880 0.017 0 56,153,880 56,153,880 XXX 0 21,738,353 21,738,353 XXX 0 77,892,233 77,892,233 XXX 0 XXX XXX 0 0 0 0.000 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 1 (Continued) Business Subject to MLR Mini-Med Plans Comprehensive Health Coverage 1 2 Small Group Employer Individual 10. 3 Large Group Employer 4 5 Small Group Employer Individual Expatriate Plans 6 Large Group Employer 7 8 Small Group 10 11 Government Business (excluded by statute) Other Health Business 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 9 Student Health Plans Large Group 13 14 15 Subtotal (Cols. 1 through 12) Uninsured Plans Total 13 + 14 General and Administrative (G&A) Expenses: 10.1 Direct sales salaries and benefits 10.2 Agents and brokers fees and commissions 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 25,000 82,741,711 25,000 82,741,711 0 0 25,000 82,741,711 10.3 Other taxes (excluding taxes on Lines 1.5 through 1.7 and Line 14 below) 10.4 Other general and administrative expenses 10.4a Community Benefit Expenditures (informational only) 10.5 Total general and administrative (Lines 10.1 +10.2 + 10.3 + 10.4) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 179,184,002 0 261,950,713 0 179,184,002 0 261,950,713 0 75,831,462 0 75,831,462 0 255,015,464 0 337,782,175 0 11. Underwriting Gain/(Loss) (Lines 1.12 - 5.7 - 6.6 - 8.3 - 10.5) (15,599,593) (15,599,593) XXX 12. Income from fees of uninsured plans XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 110,537,351 13. Net investment and other gain/(loss) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 39,952,337 XXX 14. Federal income taxes (excluding taxes on Line 1.5 above) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 XXX 0 15. Net gain or (loss) (Lines 11 + 12 + 13 - 14) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 24,352,744 XXX 28,262,633 16. ICD-10 Implementation Expenses (informational only; already included in general expenses and line 10.4) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16. 16a ICD-10 Implementation Expenses (informational only; already included in line 10.4) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 (122,227,055) 110,537,351 39,952,337 OTHER INDICATORS: 216-2.GT 1. Number of certificates/policies 0 0 0 0 0 0 0 0 0 0 0 4,868,345 4,868,345 1,308,011 6,176,356 2. Number of Covered Lives 0 0 0 0 0 0 0 0 0 0 0 4,868,345 4,868,345 1,308,011 6,176,356 3. Number of Groups 0 0 0 0 0 0 0 0 0 11 11 95 106 4. Member Months 0 0 0 0 0 0 0 0 0 58,090,814 58,090,814 15,213,696 73,304,510 XXX 0 Is run off business reported in Columns 1 through 9 or 12? Yes [ ] No [ ] If yes, show the amount of premiums and claims included. Premiums $ XXX 0 0 Claims $ AFFORDABLE CARE ACT (ACA) RECEIPTS, PAYMENTS, RECEIVABLES and PAYABLES Current Year Prior Year Comprehensive Health Coverage Comprehensive Health Coverage 1 2 3 4 Small Group Small Group Individual Plans Employer Plans Individual Plans Employer Plans ACA Receivables and Payables 1. Permanent ACA Risk Adjustment Program 1.0 Premium adjustments receivable/(payable) 2. Transitional ACA Reinsurance Program 2.0 Total amounts recoverable for claims (paid & unpaid) 3. Temporary ACA Risk Corridors Program 3.1 Accrued retrospective premium 3.2 Reserve for rate credits or policy experience refunds ACA Receipts and Payments 4. Permanent ACA Risk Adjustment Program 4.0 Premium adjustments receipts/(payments) 5. Transitional ACA Reinsurance Program 5.0 Amounts received for claims 6. Temporary ACA Risk Corridors Program 6.1 Retrospective premium received 6.2 Rate credits or policy experience refunds paid XXX XXX NONE XXX XXX 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 2 REPORT FOR: 1. CORPORATION NAIC Group Code 0001 (To Be Filed by April 1 - Not for Rebate Purposes) 2. SilverScript Insurance Company BUSINESS IN THE STATE OF 445 Great Circle Road Nashville, TN 37228 Grand Total DURING THE YEAR Comprehensive Health Coverage 1 2 3 Individual Small Group Employer Large Group Employer Small Group Employer Individual Expatriate Plans: 7 8 6 Large Group Employer Small Group 10 11 Government Business (excluded by statute) Other Health Business 9 Student Health Plans Large Group 12575 12 Medicare Advantage Part C and Medicare Part D Stand-Alone Subject to ACA 13 Total (a) 1. 216-3.GT Health Premiums Earned: 0 1.1 Direct premiums written 0 1.2 Unearned premium prior year 0 1.3 Unearned premium current year 0 1.4 Change in unearned premium (Lines 1.2 - 1.3) 0 1.5 Paid rate credits 0 1.6 Reserve for rate credits current year 0 1.7 Reserve for rate credits prior year 0 1.8 Change in reserve for rate credits (Lines 1.6 - 1.7) 0 1.9 Premium balances written off 0 1.10 Group conversion charge 0 1.11 Total direct premiums earned (Lines 1.1 + 1.4 - 1.9 + 1.10) 0 1.12 Assumed premiums earned from non-affiliates 0 1.13 Net Assumed less Ceded premiums earned from affiliates 0 1.14 Ceded premiums earned to non-affiliates 0 1.15 Other Adjustments due to MLR calculation - Premiums 0 1.16 Net premiums earned (Lines 1.11 - 1.5 - 1.8 + 1.12 + 1.13 - 1.14 + 1.15) 2. Direct Claims Incurred: 0 2.1 Paid claims during the year 0 2.2 Direct claim liability current year 0 2.3 Direct claim liability prior year 0 2.4 Direct claim reserves current year 0 2.5 Direct claim reserves prior year 0 2.6 Direct contract reserves current year 0 2.7 Direct contract reserves prior year 0 2.8 Paid rate credits 0 2.9 Reserve for rate credits current year 0 2.10 Reserve for rate credits prior year 0 2.11 Incurred medical incentive pools and bonuses (Lines 2.11a + 2.11b - 2.11c) 0 2.11a Paid medical incentive pools and bonuses current year 0 2.11b Accrued medical incentive pools and bonuses current year 0 2.11c Accrued medical incentive pools and bonuses prior year 0 2.12 Net healthcare receivables (Lines 2.12a - 2.12b) 0 2.12a Healthcare receivables current year 0 2.12b Healthcare receivables prior year 0 2.13 Group conversion charge 0 2.14 Multi-option coverage blended rate adjustment 2.15 Total incurred claims (Lines 2.1 + 2.2 - 2.3 + 2.4 - 2.5 + 2.6 - 2.7 + 2.8 + 2.9 0 2.10 + 2.11 - 2.12 + 2.13 + 2.14) 0 2.16 Assumed incurred claims from non-affiliates 0 2.17 Net assumed less ceded incurred claims from affiliates 0 2.18 Ceded incurred claims to non-affiliates 0 2.19 Other adjustments due to MLR calculation - Claims 0 2.20 Net Incurred Claims (Lines 2.15 - 2.8 - 2.9 + 2.10 + 2.16 + 2.17 - 2.18 + 2.19) 3. Fraud and Abuse Recoveries that Reduced PAID Claims in Line 2.1 above 0 (informational only) 0 for stand-alone dental and $ (a) Column 13, Line 1.1 includes direct written premium of $ 4 Business Subject to MLR Mini-Med Plans 5 (LOCATION) NAIC Company Code 2018 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,348,116,947 0 0 0 (650,493) 7,646,715 29,164,350 (21,517,635) 1,774,120 0 3,346,342,827 (102,714) (677,172,865) (102,714) 0 2,691,338,090 3,348,116,947 0 0 0 (650,493) 7,646,715 29,164,350 (21,517,635) 1,774,120 0 3,346,342,827 (102,714) (677,172,865) (102,714) 0 2,691,338,090 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,702,349,287 8,462,012 5,646,863 0 0 0 0 (650,493) 7,646,715 29,164,350 209,901 895,247 50,000 735,346 (100,051,550) 523,029,620 623,081,170 0 0 2,702,349,287 8,462,012 5,646,863 0 0 0 0 (650,493) 7,646,715 29,164,350 209,901 895,247 50,000 735,346 (100,051,550) 523,029,620 623,081,170 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2,783,257,759 (184,222) (551,840,212) (184,222) 0 2,253,585,675 2,783,257,759 (184,222) (551,840,212) (184,222) 0 2,253,585,675 0 0 0 0 0 for stand-alone vision policies. 0 0 0 0 0 0 0 0 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (To Be Filed by April 1 - Not for Rebate Purposes) 2. REPORT FOR: 1. CORPORATION NAIC Group Code BUSINESS IN THE STATE OF Grand Total DURING THE YEAR All Expenses 1 Improve Health Outcomes 1. Individual Comprehensive Coverage Expenses: 1.1 Salaries (including $ 2 Activities to Prevent Hospital Readmissions Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses 6 Total (1 to 5) 2018 (LOCATION) NAIC Company Code Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 1.2 1.3 1.4 1.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 1.6 1.7 1.8 1.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 1.1 to 1.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 1.10 Total (1.7 to 1.9) 1.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 2. 216-4.GT Small Group Comprehensive Coverage Expenses: 2.1 Salaries (including $ for affiliated services) 2.2 Outsourced Services 2.3 2.4 2.5 2.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ for affiliated services) for affiliated services) for affiliated services) for affiliated services) 2.7 Subtotal before Reimbursements and Taxes (Lines 2.1 to 2.6) 2.8 Reimbursements by uninsured plans and fiscal intermediaries 2.9 Taxes, Licenses and Fees (in total, for tying purposes) 2.10 Total (2.7 to 2.9) NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 2.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 3. Large Group Comprehensive Coverage Expenses: 3.1 Salaries (including $ for affiliated services) 3.2 3.3 3.4 3.5 Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ 3.6 3.7 3.8 3.9 Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 3.1 to 3.6) Reimbursements by uninsured plans and fiscal intermediaries Taxes, Licenses and Fees (in total, for tying purposes) for affiliated services) for affiliated services) for affiliated services) 3.10 Total (3.7 to 3.9) 3.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 4. 4.1 4.2 4.3 4.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 4.5 4.6 4.7 4.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 4.1 to 4.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Small Group Mini-Med Plans Expenses: 5.1 Salaries (including $ 216-5.GT 5.4 5.5 5.6 5.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 5.1 to 5.6) 5.8 Reimbursements by uninsured plans and fiscal intermediaries 5.9 Taxes, Licenses and Fees (in total, for tying purposes) 5.10 Total (5.7 to 5.9) 5.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Large Group Mini-Med Plans Expenses: 6.1 Salaries (including $ 6.2 Outsourced Services 6.3 6.4 6.5 6.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 5.2 Outsourced Services 5.3 EDP Equipment and Software (incl $ 6. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Individual Mini-Med Plans Expenses: 4.9 Taxes, Licenses and Fees (in total, for tying purposes) 4.10 Total (4.7 to 4.9) 4.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 5. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 6.7 Subtotal before Reimbursements and Taxes (Lines 6.1 to 6.6) 6.8 Reimbursements by uninsured plans and fiscal intermediaries 6.9 Taxes, Licenses and Fees (in total, for tying purposes) 6.10 Total (6.7 to 6.9) 6.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company SUPPLEMENTAL HEALTH CARE EXHIBIT - PART 3 (Continued) All Expenses 1 Improve Health Outcomes 7. 7.1 7.2 7.3 7.4 Salaries (including $ Outsourced Services EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ 6 Total (1 to 5) Claims Adjustment Expenses 7 8 Other Cost Claims Containment Adjustment Expenses Expenses for affiliated services) 7.5 7.6 7.7 7.8 Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 7.1 to 7.6) Reimbursements by uninsured plans and fiscal intermediaries for affiliated services) for affiliated services) Large Group Expatriate Plans Expenses: 8.1 Salaries (including $ 216-6.GT 8.4 8.5 8.6 8.7 for affiliated services) Other Equipment (excl. EDP) (incl $ for affiliated services) Accreditation and Certification (incl $ for affiliated services) Other Expenses (incl $ for affiliated services) Subtotal before Reimbursements and Taxes (Lines 8.1 to 8.6) 8.8 Reimbursements by uninsured plans and fiscal intermediaries 8.9 Taxes, Licenses and Fees (in total, for tying purposes) 8.10 Total (8.7 to 8.9) 8.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) Student Health Plans Expenses: 9.1 Salaries (including $ 9.2 Outsourced Services 9.3 9.4 9.5 9.6 EDP Equipment and Software (incl $ Other Equipment (excl. EDP) (incl $ Accreditation and Certification (incl $ Other Expenses (incl $ XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) 8.2 Outsourced Services 8.3 EDP Equipment and Software (incl $ 9. Improving Health Care Quality Expenses 3 4 5 Improve Wellness & Patient Safety Health and Reduce Promotion HIT Medical Errors Activities Expenses Small Group Expatriate Plans Expenses: 7.9 Taxes, Licenses and Fees (in total, for tying purposes) 7.10 Total (7.7 to 7.9) 7.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) 8. 2 Activities to Prevent Hospital Readmissions NONE XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX for affiliated services) for affiliated services) for affiliated services) for affiliated services) for affiliated services) 9.7 Subtotal before Reimbursements and Taxes (Lines 9.1 to 9.6) 9.8 Reimbursements by uninsured plans and fiscal intermediaries 9.9 Taxes, Licenses and Fees (in total, for tying purposes) 9.10 Total (9.7 to 9.9) 9.11 Total Fraud and Abuse Detection/Recovery Expenses included in Column 7 (informational only) XXX 9 10 General Administrative Expenses Total Expenses (6 to 9) *12575201828500100* SUPPLEMENTAL INVESTMENT RISKS INTERROGATORIES For The Year Ended December 31, 2018 (To Be Filed by April 1) Of The SilverScript Insurance Company ADDRESS (City, State and Zip Code) NAIC Group Code Nashville , TN 37228 0001 NAIC Company Code 12575 Federal Employer's Identification Number (FEIN) 20-2833904 The Investment Risks Interrogatories are to be filed by April 1. They are also to be included with the Audited Statutory Financial Statements. Answer the following interrogatories by reporting the applicable U.S. dollar amounts and percentages of the reporting entity’s total admitted assets held in that category of investments. 1. Reporting entity’s total admitted assets as reported on Page 2 of this annual statement. 2. Ten largest exposures to a single issuer/borrower/investment. $ 1 2 3 Issuer Description of Exposure Amount 2,371,801,053 4 Percentage of Total Admitted Assets 2.01 $ 0.0 % 2.02 $ 0.0 % 2.03 $ 0.0 % 2.04 $ 0.0 % 2.05 $ 0.0 % 2.06 $ 0.0 % 2.07 $ 0.0 % 2.08 $ 0.0 % 2.09 $ 0.0 % 2.10 $ 0.0 % 3. Amounts and percentages of the reporting entity’s total admitted assets held in bonds and preferred stocks by NAIC designation. Bonds 1 2 Preferred Stocks 3 4 3.01 NAIC-1 $ 2,691,717 0.1 % 3.07 P/RP-1 $ 0.0 % 3.02 NAIC-2 $ 0 0.0 % 3.08 P/RP-2 $ 0.0 % 3.03 NAIC-3 $ 0 0.0 % 3.09 P/RP-3 $ 0.0 % 3.04 NAIC-4 $ 0 0.0 % 3.10 P/RP-4 $ 0.0 % 3.05 NAIC-5 $ 0 0.0 % 3.11 P/RP-5 $ 0.0 % $ 0 0.0 % 3.12 P/RP-6 $ 0.0 % 3.06 NAIC-6 4. 4.01 Assets held in foreign investments: Yes [ X ] No [ Are assets held in foreign investments less than 2.5% of the reporting entity’s total admitted assets? ] If response to 4.01 above is yes, responses are not required for interrogatories 5 - 10. 4.02 Total admitted assets held in foreign investments $ 0.0 % 4.03 Foreign-currency-denominated investments $ 0.0 % 4.04 Insurance liabilities denominated in that same foreign currency $ 0.0 % 285 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company 5. Aggregate foreign investment exposure categorized by NAIC sovereign designation: 1 5.01 5.02 5.03 6. 2 0.0 % 0.0 % 0.0 % $ $ $ Countries designated NAIC-1 Countries designated NAIC-2 Countries designated NAIC-3 or below Largest foreign investment exposures by country, categorized by the country’s NAIC sovereign designation: 1 2 Countries designated NAIC - 1: 6.01 6.02 Country 1: Country 2: Countries designated NAIC - 2: $ $ 0.0 % 0.0 % 6.03 6.04 Country 1: Country 2: Countries designated NAIC - 3 or below: $ $ 0.0 % 0.0 % 6.05 6.06 Country 1: Country 2: $ $ 0.0 % 0.0 % 7. Aggregate unhedged foreign currency exposure $ 8. Aggregate unhedged foreign currency exposure categorized by NAIC sovereign designation: 1 0.0 % 1 8.01 8.02 8.03 9. 2 2 0.0 % 0.0 % 0.0 % $ $ $ Countries designated NAIC-1 Countries designated NAIC-2 Countries designated NAIC-3 or below Largest unhedged foreign currency exposures by country, categorized by the country’s NAIC sovereign designation: 1 2 Countries designated NAIC - 1: 9.01 9.02 Country 1: Country 2: Countries designated NAIC - 2: $ $ 0.0 % 0.0 % 9.03 9.04 Country 1: Country 2: Countries designated NAIC - 3 or below: $ $ 0.0 % 0.0 % 9.05 9.06 Country 1: Country 2: $ $ 0.0 % 0.0 % 10. Ten largest non-sovereign (i.e. non-governmental) foreign issues: 1 Issuer 2 NAIC Designation 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 10.10 3 $ $ $ $ $ $ $ $ $ $ 285.1 4 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 % % % % % % % % % % SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company 11. Amounts and percentages of the reporting entity’s total admitted assets held in Canadian investments and unhedged Canadian currency exposure: 11.01 Are assets held in Canadian investments less than 2.5% of the reporting entity’s total admitted assets? Yes [ X ] No [ ] If response to 11.01 is yes, detail is not required for the remainder of interrogatory 11. 1 11.02 11.03 11.04 11.05 12. 2 0.0 0.0 0.0 0.0 $ $ $ $ Total admitted assets held in Canadian investments Canadian-currency-denominated investments Canadian-denominated insurance liabilities Unhedged Canadian currency exposure % % % % Report aggregate amounts and percentages of the reporting entity’s total admitted assets held in investments with contractual sales restrictions: 12.01 Are assets held in investments with contractual sales restrictions less than 2.5% of the reporting entity’s total admitted assets? Yes [ X ] No [ ] If response to 12.01 is yes, responses are not required for the remainder of Interrogatory 12. 1 12.02 Aggregate statement value of investments with contractual sales restrictions Largest three investments with contractual sales restrictions: $ 0.0 % 12.03 12.04 12.05 $ $ $ 0.0 % 0.0 % 0.0 % 13. 2 3 Amounts and percentages of admitted assets held in the ten largest equity interests: Yes [ X ] No [ 13.01 Are assets held in equity interests less than 2.5% of the reporting entity’s total admitted assets? ] If response to 13.01 above is yes, responses are not required for the remainder of Interrogatory 13. 1 Issuer 2 $ $ $ $ $ $ $ $ $ $ 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 285.2 3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 % % % % % % % % % % SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company 14. Amounts and percentages of the reporting entity’s total admitted assets held in nonaffiliated, privately placed equities: Yes [ X ] No [ 14.01 Are assets held in nonaffiliated, privately placed equities less than 2.5% of the reporting entity’s total admitted assets? ] If response to 14.01 above is yes, responses are not required for the remainder of Interrogatory 14. 1 14.02 Aggregate statement value of investments held in nonaffiliated, privately placed equities Largest three investments held in nonaffiliated, privately placed equities: $ 0.0 % 14.03 14.04 14.05 $ $ $ 0.0 % 0.0 % 0.0 % 15. 2 3 Amounts and percentages of the reporting entity’s total admitted assets held in general partnership interests: Yes [ X ] No [ 15.01 Are assets held in general partnership interests less than 2.5% of the reporting entity’s total admitted assets? If response to 15.01 above is yes, responses are not required for the remainder of Interrogatory 15. 1 2 ] 3 15.02 Aggregate statement value of investments held in general partnership interests Largest three investments in general partnership interests: $ 0.0 % 15.03 15.04 15.05 $ $ $ 0.0 % 0.0 % 0.0 % 16. Amounts and percentages of the reporting entity's total admitted assets held in mortgage loans: Yes [ X ] No [ 16.01 Are mortgage loans reported in Schedule B less than 2.5% of the reporting entity’s total admitted assets? ] If response to 16.01 above is yes, responses are not required for the remainder of Interrogatory 16 and Interrogatory 17. 1 Type (Residential, Commercial, Agricultural) 2 16.02 16.03 16.04 16.05 16.06 16.07 16.08 16.09 16.10 16.11 $ $ $ $ $ $ $ $ $ $ 285.3 3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 % % % % % % % % % % SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company Amount and percentage of the reporting entity's total admitted assets held in the following categories of mortgage loans: Loans 16.12 Construction loans $ 16.13 16.14 16.15 16.16 $ $ $ $ 17. Mortgage loans over 90 days past due Mortgage loans in the process of foreclosure Mortgage loans foreclosed Restructured mortgage loans Residential 18. % 0.0 0.0 0.0 0.0 0.0 % % % % % % % % % Aggregate mortgage loans having the following loan-to-value ratios as determined from the most current appraisal as of the annual statement date: Loan to Value 17.01 17.02 17.03 17.04 17.05 0.0 0.0 0.0 0.0 0.0 above 95% 91 to 95% 81 to 90% 71 to 80% below 70% 1 $ $ $ $ $ Commercial 2 3 0.0 0.0 0.0 0.0 0.0 % % % % % Agricultural 4 5 0.0 0.0 0.0 0.0 0.0 $ $ $ $ $ % % % % % 6 $ $ $ $ $ Amounts and percentages of the reporting entity’s total admitted assets held in each of the five largest investments in real estate: Yes [ X ] No [ 18.01 Are assets held in real estate reported less than 2.5% of the reporting entity’s total admitted assets? ] If response to 18.01 above is yes, responses are not required for the remainder of Interrogatory 18. Largest five investments in any one parcel or group of contiguous parcels of real estate. Description 1 18.02 18.03 18.04 18.05 18.06 19. 2 3 0.0 0.0 0.0 0.0 0.0 $ $ $ $ $ % % % % % Report aggregate amounts and percentages of the reporting entity’s total admitted assets held in investments held in mezzanine real estate loans: 19.01 Are assets held in investments held in mezzanine real estate loans less than 2.5% of the reporting entity’s total admitted assets? If response to 19.01 is yes, responses are not required for the remainder of Interrogatory 19. 1 2 Yes [ X ] No [ ] 3 19.02 Aggregate statement value of investments held in mezzanine real estate loans: Largest three investments held in mezzanine real estate loans: $ 0.0 % 19.03 19.04 19.05 $ $ $ 0.0 % 0.0 % 0.0 % 285.4 SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company 20. Amounts and percentages of the reporting entity’s total admitted assets subject to the following types of agreements: At Year End 1 20.01 Securities lending agreements (do not include assets held as collateral for such transactions) 20.02 Repurchase agreements 20.03 Reverse repurchase agreements 20.04 Dollar repurchase agreements 20.05 Dollar reverse repurchase agreements 21. 1st Quarter 3 2 0.0 0.0 0.0 0.0 0.0 $ $ $ $ $ % % % % % $ $ $ $ $ At End of Each Quarter 2nd Quarter 4 $ $ $ $ $ Owned 21.01 Hedging 21.02 Income generation 21.03 Other Written 2 3 $ $ $ 0.0 % 0.0 % 0.0 % Hedging Income generation Replications Other 2 0 0 0 0 $ $ $ $ 1st Quarter 3 0.0 0.0 0.0 0.0 % % % % $ $ $ $ At End of Each Quarter 2nd Quarter 4 $ $ $ $ 3rd Quarter 5 $ $ $ $ Amounts and percentages of the reporting entity's total admitted assets of potential exposure for futures contracts: At Year End 1 23.01 23.02 23.03 23.04 0.0 % 0.0 % 0.0 % Amounts and percentages of the reporting entity's total admitted assets of potential exposure for collars, swaps, and forwards: 1 23. 4 $ $ $ At Year End 22.01 22.02 22.03 22.04 $ $ $ $ $ Amounts and percentages of the reporting entity's total admitted assets for warrants not attached to other financial instruments, options, caps, and floors: 1 22. 3rd Quarter 5 Hedging Income generation Replications Other $ $ $ $ 1st Quarter 3 2 0 0.0 0.0 0.0 0.0 285.5 % % % % $ $ $ $ At End of Each Quarter 2nd Quarter 4 $ $ $ $ $ $ $ $ 3rd Quarter 5 *12575201829001100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Alabama 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 53,937,505 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53,937,505 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 53,937,505 53,937,505 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 53,937,505 0 0 0 0 0 0 0 53,937,505 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.AL *12575201830001100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Alabama 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.AL *12575201829002100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Alaska 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 1,182,107 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1,182,107 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 1,182,107 1,182,107 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 1,182,107 0 0 0 0 0 0 0 1,182,107 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.AK *12575201830002100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Alaska 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.AK *12575201829003100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Arizona 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 35,071,421 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35,071,421 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 35,071,421 35,071,421 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 35,071,421 0 0 0 0 0 0 0 35,071,421 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.AZ *12575201830003100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Arizona 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.AZ *12575201829004100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Arkansas 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 54,830,510 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 54,830,510 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 54,830,510 54,830,510 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 54,830,510 0 0 0 0 0 0 0 54,830,510 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.AR *12575201830004100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Arkansas 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.AR *12575201829005100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: California 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 376,781,506 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 376,781,506 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 376,781,506 376,781,506 0 0 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 376,781,506 0 0 0 0 0 0 0 376,781,506 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.CA *12575201830005100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: California 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.CA *12575201829006100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Colorado 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 27,116,168 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27,116,168 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 27,116,168 27,116,168 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 27,116,168 0 0 0 0 0 0 0 27,116,168 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.CO *12575201830006100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Colorado 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.CO *12575201829007100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Connecticut 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 43,199,425 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43,199,425 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 43,199,425 43,199,425 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 43,199,425 0 0 0 0 0 0 0 43,199,425 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.CT *12575201830007100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Connecticut 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.CT *12575201829008100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Delaware 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 10,104,281 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,104,281 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 10,104,281 10,104,281 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 10,104,281 0 0 0 0 0 0 0 10,104,281 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.DE *12575201830008100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Delaware 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.DE *12575201829009100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: District of Columbia 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 5,460,210 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5,460,210 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 5,460,210 5,460,210 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 5,460,210 0 0 0 0 0 0 0 5,460,210 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.DC *12575201830009100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: District of Columbia 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.DC *12575201829010100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Florida 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 312,454,595 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 312,454,595 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 312,454,595 312,454,595 0 0 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 312,454,595 0 0 0 0 0 0 0 312,454,595 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.FL *12575201830010100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Florida 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.FL *12575201829011100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Georgia 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 106,633,292 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 106,633,292 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 106,633,292 106,633,292 0 0 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 106,633,292 0 0 0 0 0 0 0 106,633,292 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.GA *12575201829012100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Hawaii 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 4,169,629 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4,169,629 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 4,169,629 4,169,629 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 4,169,629 0 0 0 0 0 0 0 4,169,629 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.HI *12575201830012100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Hawaii 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.HI *12575201829013100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Idaho 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 14,908,536 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14,908,536 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 14,908,536 14,908,536 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 14,908,536 0 0 0 0 0 0 0 14,908,536 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.ID *12575201830013100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Idaho 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.ID *12575201829014100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Illinois 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 104,477,443 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 104,477,443 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 104,477,443 104,477,443 0 0 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 104,477,443 0 0 0 0 0 0 0 104,477,443 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.IL *12575201830014100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Illinois 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.IL *12575201829015100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Indiana 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 69,617,752 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 69,617,752 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 69,617,752 69,617,752 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 69,617,752 0 0 0 0 0 0 0 69,617,752 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.IN *12575201830015100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Indiana 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.IN *12575201829016100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Iowa 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 42,800,853 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42,800,853 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 42,800,853 42,800,853 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 42,800,853 0 0 0 0 0 0 0 42,800,853 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.IA *12575201830016100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Iowa 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.IA *12575201829017100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Kansas 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 40,463,170 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40,463,170 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 40,463,170 40,463,170 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 40,463,170 0 0 0 0 0 0 0 40,463,170 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.KS *12575201830017100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Kansas 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.KS *12575201829018100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Kentucky 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 59,906,508 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 59,906,508 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 59,906,508 59,906,508 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 59,906,508 0 0 0 0 0 0 0 59,906,508 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.KY *12575201830018100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Kentucky 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.KY *12575201829019100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Louisiana 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 69,647,616 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 69,647,616 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 69,647,616 69,647,616 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 69,647,616 0 0 0 0 0 0 0 69,647,616 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.LA *12575201830019100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Louisiana 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.LA *12575201829020100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Maine 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 7,529,328 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,529,328 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 7,529,328 7,529,328 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 7,529,328 0 0 0 0 0 0 0 7,529,328 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.ME *12575201830020100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Maine 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.ME *12575201829021100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Maryland 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 57,261,503 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 57,261,503 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 57,261,503 57,261,503 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 57,261,503 0 0 0 0 0 0 0 57,261,503 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.MD *12575201830021100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Maryland 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.MD *12575201829022100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Massachusetts 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 99,032,228 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 99,032,228 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 99,032,228 99,032,228 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 99,032,228 0 0 0 0 0 0 0 99,032,228 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.MA *12575201830022100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Massachusetts 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.MA *12575201829023100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Michigan 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 74,825,170 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 74,825,170 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 74,825,170 74,825,170 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 74,825,170 0 0 0 0 0 0 0 74,825,170 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.MI *12575201830023100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Michigan 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.MI *12575201829024100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Minnesota 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 48,994,211 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 48,994,211 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 48,994,211 48,994,211 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 48,994,211 0 0 0 0 0 0 0 48,994,211 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.MN *12575201830024100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Minnesota 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.MN *12575201829025100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Mississippi 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 58,936,413 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 58,936,413 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 58,936,413 58,936,413 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 58,936,413 0 0 0 0 0 0 0 58,936,413 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.MS *12575201830025100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Mississippi 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.MS *12575201829026100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Missouri 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 99,963,338 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 99,963,338 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 99,963,338 99,963,338 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 99,963,338 0 0 0 0 0 0 0 99,963,338 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.MO *12575201830026100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Missouri 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.MO *12575201829027100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Montana 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 13,707,710 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13,707,710 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 13,707,710 13,707,710 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 13,707,710 0 0 0 0 0 0 0 13,707,710 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.MT *12575201830027100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Montana 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.MT *12575201829028100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Nebraska 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 24,926,553 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24,926,553 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 24,926,553 24,926,553 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 24,926,553 0 0 0 0 0 0 0 24,926,553 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.NE *12575201830028100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Nebraska 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.NE *12575201829029100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Nevada 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 10,478,598 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10,478,598 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 10,478,598 10,478,598 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 10,478,598 0 0 0 0 0 0 0 10,478,598 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.NV *12575201830029100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Nevada 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.NV *12575201829030100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: New Hampshire 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 11,132,647 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,132,647 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 11,132,647 11,132,647 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 11,132,647 0 0 0 0 0 0 0 11,132,647 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.NH *12575201830030100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: New Hampshire 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.NH *12575201829031100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: New Jersey 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 105,383,525 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 105,383,525 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 105,383,525 105,383,525 0 0 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 105,383,525 0 0 0 0 0 0 0 105,383,525 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.NJ *12575201830031100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: New Jersey 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.NJ *12575201829032100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: New Mexico 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 21,483,423 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21,483,423 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 21,483,423 21,483,423 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 21,483,423 0 0 0 0 0 0 0 21,483,423 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.NM *12575201830032100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: New Mexico 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.NM *12575201829033100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: New York 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 202,294,875 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 202,294,875 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 0 0 0 0 0 202,294,875 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 0 0 0 0 0 0 0 0 290.NY *12575201830033100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: New York 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 202,294,875 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 202,294,875 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.NY *12575201829034100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: North Carolina 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 127,864,248 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 127,864,248 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 127,864,248 127,864,248 0 0 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 127,864,248 0 0 0 0 0 0 0 127,864,248 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.NC *12575201829035100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: North Dakota 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 13,587,851 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13,587,851 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 13,587,851 13,587,851 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 13,587,851 0 0 0 0 0 0 0 13,587,851 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.ND *12575201830035100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: North Dakota 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.ND *12575201829036100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Ohio 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 122,397,717 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 122,397,717 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 122,397,717 122,397,717 0 0 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 122,397,717 0 0 0 0 0 0 0 122,397,717 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.OH *12575201830036100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Ohio 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.OH *12575201829037100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Oklahoma 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 57,304,197 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 57,304,197 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 57,304,197 57,304,197 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 57,304,197 0 0 0 0 0 0 0 57,304,197 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.OK *12575201830037100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Oklahoma 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.OK *12575201829038100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Oregon 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 27,699,191 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27,699,191 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 27,699,191 27,699,191 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 27,699,191 0 0 0 0 0 0 0 27,699,191 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.OR *12575201830038100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Oregon 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.OR *12575201829039100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Pennsylvania 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 160,968,128 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 160,968,128 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 0 0 0 0 0 160,968,128 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 0 0 0 0 0 0 0 0 290.PA *12575201829040100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Rhode Island 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 9,364,908 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9,364,908 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 9,364,908 9,364,908 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 9,364,908 0 0 0 0 0 0 0 9,364,908 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.RI *12575201830040100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Rhode Island 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.RI *12575201829041100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: South Carolina 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 56,693,453 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56,693,453 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 56,693,453 56,693,453 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 56,693,453 0 0 0 0 0 0 0 56,693,453 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.SC *12575201830041100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: South Carolina 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.SC *12575201829042100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: South Dakota 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 12,708,596 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,708,596 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 12,708,596 12,708,596 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 12,708,596 0 0 0 0 0 0 0 12,708,596 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.SD *12575201830042100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: South Dakota 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.SD *12575201829043100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Tennessee 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 67,096,128 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 67,096,128 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 67,096,128 67,096,128 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 67,096,128 0 0 0 0 0 0 0 67,096,128 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.TN *12575201830043100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Tennessee 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.TN *12575201829044100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Texas 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 173,744,294 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 173,744,294 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 0 173,744,294 173,744,294 0 0 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 173,744,294 0 0 0 0 0 0 0 173,744,294 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.TX *12575201830044100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Texas 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.TX *12575201829045100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Utah 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 11,648,293 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11,648,293 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 11,648,293 11,648,293 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 11,648,293 0 0 0 0 0 0 0 11,648,293 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.UT *12575201830045100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Utah 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.UT *12575201829046100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Vermont 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 12,535,971 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12,535,971 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 12,535,971 12,535,971 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 12,535,971 0 0 0 0 0 0 0 12,535,971 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.VT *12575201830046100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Vermont 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.VT *12575201829047100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Virginia 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 71,363,736 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 71,363,736 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 71,363,736 71,363,736 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 71,363,736 0 0 0 0 0 0 0 71,363,736 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.VA *12575201830047100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Virginia 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.VA *12575201829048100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Washington 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 56,885,296 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56,885,296 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 56,885,296 56,885,296 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 56,885,296 0 0 0 0 0 0 0 56,885,296 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.WA *12575201830048100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Washington 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.WA *12575201829049100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: West Virginia 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 32,090,139 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 32,090,139 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 32,090,139 32,090,139 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 32,090,139 0 0 0 0 0 0 0 32,090,139 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.WV *12575201830049100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: West Virginia 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.WV *12575201829050100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Wisconsin 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 58,651,850 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 58,651,850 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 58,651,850 58,651,850 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 58,651,850 0 0 0 0 0 0 0 58,651,850 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.WI *12575201830050100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Wisconsin 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.WI *12575201829051100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Wyoming 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 7,023,752 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7,023,752 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 7,023,752 7,023,752 0 0 0 0 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 7,023,752 0 0 0 0 0 0 0 7,023,752 0 0 Medicare part D Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 290.WY *12575201830051100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Wyoming 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 0 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.WY *12575201829054100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Puerto Rico 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 372,426 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 372,426 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX XXX 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 0 0 0 0 0 0 0 372,426 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 0 0 0 0 0 0 0 0 290.PR *12575201830054100* ADJUSTMENTS TO THE LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Puerto Rico 1 2 Allocated Annuity and Other Allocated Fund Deposits Life Insurance Premiums 3 Accident & Health Premium 0 0 AMOUNTS REQUIRED TO DETERMINE THIS STATE’S ASSESSMENT BASE 1. MODEL ACT BASE ( Line 11 of the Reconciliation Exhibit) 2. Enter in Column 2, as a positive number, and Column 4, as a negative number, the total of all amounts received to fund allocated contracts established under Section 403(b) of the U.S. Internal Revenue Code that are included in Column 4, Line 1 above 3. Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans: XXX 372,426 0 XXX 3.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 3.2 All amounts XXX XXX XXX 4.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 4.2 Amounts in excess of $1 million but NOT in excess of $5 million per contract XXX XXX XXX 4.3 Amounts in excess of $5 million per contract XXX XXX XXX 4.4 Total (Lines 4.1 + 4.2 + 4.3) XXX XXX XXX 4.5 Amounts up to $7.5 million, per contract (Minnesota only) XXX XXX XXX 5.1 Amounts in excess of $1 million per contract XXX XXX XXX 5.2 All amounts XXX XXX XXX 5.3 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 5.4 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 6.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 6.2 Amounts in excess of $1 million per contract XXX XXX XXX 6.3 Total (Lines 6.1 + 6.2) XXX XXX XXX 6.4 Amounts in excess of $2 million per contract (New Jersey Only) XXX XXX XXX 6.5 Amounts not in excess of $7.5 million per contract (Minnesota Only) XXX XXX XXX 7.1 Amounts NOT in excess of $1 million per contract XXX XXX XXX 7.2 All amounts XXX XXX XXX 7.3 Amounts NOT in excess of $2 million per contract (New Jersey only) XXX XXX XXX 8. Unallocated funding obligations issued to fund government lotteries NOT in excess of $5 million per contractholder (New Jersey Only) XXX XXX XXX 9. Unallocated funding obligations that fund employee or association of natural persons benefit plans in excess of $2 million but NOT in excess of $5 million per contract (New Jersey Only) XXX 4. 4 Unallocated Annuity & Other Unallocated Fund Deposits Unallocated funding obligations issued to fund government lotteries or employee, union, or association of natural persons benefit plans which are NOT: (a) governmental retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation: 5. 6. 7. 10. 0 0 Unallocated funding obligations issued to fund governmental retirement plans established under Sections 401 and 457 of the U.S. Internal Revenue Code: Unallocated funding obligations issued to fund governmental retirement plans established under Sections 403(b) of the U.S. Internal Revenue Code: 0 Unallocated funding obligations that fund employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation: Aggregate write-ins for other deductions XXX XXX 0 0 0 0 0 0 372,426 0 0 0 0 0 0 0 0 0 BASE 11. Current Year (2018) DETAILS OF WRITE-INS 1001. 1002. 1003. 1098. Summary of remaining write-ins for Line 10 from overflow page 1099. Totals (Lines 1001 thru 1003 plus 1098)(Line 10 above) 300.PR *12575201829059100* LIFE, HEALTH & ANNUITY GUARANTY ASSOCIATION MODEL ACT ASSESSMENT BASE RECONCILIATION EXHIBIT FOR THE YEAR ENDED DECEMBER 31, 2018 (To Be Filed by April 1) OF THE NAIC COMPANY CODE SilverScript Insurance Company 12575 DIRECT BUSINESS IN THE STATE OF: Grand Total 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 3.501. 3.502. 3.503. 3.598. 3.599. 0601. 0602. 0603. 0698. 0699. 0901. 0902. 0903. 0998. 0999. PREMIUMS, CONSIDERATIONS AND DEPOSITS Premiums, considerations and deposits from Schedule T or Exhibit of Premiums and Losses Premiums, considerations and deposits NOT reported in Schedule T or Exhibit of Premiums and Losses, including investment contract receipts credited to a liability account 2.1 Contract fees for variable contracts with guarantees 2.2 Any other premiums, considerations and deposits not reported in Schedule T or Exhibit of Premiums and Losses Amounts, if applicable, that were deducted prior to determining amounts included in Lines 1 or 2 which are in the following categories: 3.1 Transfers to guaranteed Separate Accounts 3.2 Roll over of GICs or annuities into other companies 3.3 Surrenders or other benefits paid out 3.4 Excess interest credited to accounts 3.5 Aggregate write-ins for other amounts deducted prior to determining amounts included in Lines 1 or 2 3.99 Total (Lines 3.1 through 3.5) Transfers: 4.1 Enter in Column 2, as a negative number, and Column 4, as a positive number, the total of all amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, that are included in Column 2, Lines 1, 2 and 3.99 4.2 Enter in Column 2, as a positive number, and Column 4, as a negative number, any amounts reported in Column 4, Lines 1, 2 and 3.99 that are allocated. (Note: amounts received to fund contracts established under Section 403(b) of the U.S. Internal Revenue Code, should not be included in line 4.2) 4.3 Enter in Column 4, as a positive number, and Column 2, as a negative number, any amounts reported in Column 2, Lines 1, 2 and 3.99 that are unallocated 4.99 Total (Lines 4.1 + 4.2 + 4.3) Total (Lines 1 + 2 + 3.99 + 4.99) 1 2 3 Life Insurance Premiums Annuity Considerations A & H Premiums 4 Deposit-Type Contract Funds and Other Considerations 0 0 3,348,712,223 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3,348,712,223 DEVELOPMENT OF AMOUNTS INCLUDED IN LINES 1 THROUGH 5 THAT SHOULD BE DEDUCTED IN DETERMINING THE BASE Do not include any amount more than once in Lines 6 through 9 Aggregate write-ins for amounts where the insurer is not subject to risk. Premiums for portions of policies or contracts NOT guaranteed or under which the entire investment risk is borne by the policyholder. (Please specify such deductions and indicate where such amounts were reported in the Annual Statement) Amounts NOT allocated to individuals or individual certificate holders or amounts received for such contracts in excess of limits: 7.1 Unallocated funding obligations that do NOT fund government lotteries or employee, union, or association of natural persons benefit plans 7.2 Unallocated funding obligations that fund any employee, union, or association of natural persons benefit plans protected by the Federal Pension Benefit Guaranty Corporation 7.3 Unallocated funding obligations that fund governmental lotteries or employee, union, or association of natural persons benefit plans in excess of $5 million per contract which are NOT: (a) government retirement plans established under Sections 401, 403(b) or 457 of the U.S. Internal Revenue Code, or (b) protected by the Federal Pension Benefit Guaranty Corporation 7.4 Total (Lines 7.1 + 7.2 + 7.3) Dividends/Experience rating credits paid or credited, but only if NOT guaranteed in advance (include only amounts NOT already deducted in determining Lines 1 and 2) Aggregate write-ins for Other Deductions Total (Lines 6 + 7.4 + 8 + 9) Current Year DETAILS OF WRITE-INS 0 0 0 0 0 0 0 XXX XXX XXX 0 XXX XXX XXX 0 XXX XXX XXX XXX XXX XXX 0 0 0 0 0 MODEL ACT BASE (Line 5 minus Line 10) 0 0 0 0 0 2,985,076,794 2,985,076,794 0 0 0 0 363,635,429 0 Summary of remaining write-ins for Line 3.5 from overflow page Totals (Lines 3.501 thru 3.503 plus 3.598)(Line 3.5 above) 0 0 0 0 0 0 0 0 Summary of remaining write-ins for Line 6 from overflow page Totals (Lines 0601 thru 0603 plus 0698)(Line 6 above) Medicare part D 0 0 0 0 0 0 0 0 2,985,076,794 0 0 0 Summary of remaining write-ins for Line 9 from overflow page Totals (Lines 0901 thru 0903 plus 0998)(Line 9 above) 0 0 0 0 0 2,985,076,794 0 0 290.GT SUPPLEMENT FOR THE YEAR 2018 OF THE SilverScript Insurance Company Life Supplement - Analysis of Annuity Operations by Lines of Business NONE Life Supplement - Analysis of Annuity Operations by Lines of Business Overflow Page NONE Life Supplement - Analysis of Increase in Annuity Reserves During the Year NONE LS214, LS214-1, LS215