Okaloosa County BOCC — March 18, 2014 — Corizon Invoice 14508

C@RIZON INVOICE Invoice: CZN000014508 invoice Date: March 11, 2014 Page: 1 of 1 Customer No: 90398 OKALOOSA COUNTY PURCHASING DEPT. ATTN: JACK ALLEN 602 C-NORTH PEARL STREET CRESTVIEW FL 32536 Payment Due: 4/10/2014 AMOUNT DUE: 386,863.79 For billing questions, please call: 800-729-0069 EXT.1338 Fed TIN# 23-2108853 For products and services rendered by Corizon Health, Inc. for the following dates of service: Beginning: 10/01/2012 Ending: 09/30/2013 | Description Quantity UOM Unit Amt Net Amount | Aggregate Cap as of 2/27/14 1.00 EA 386,863.79 386,863.79 This replaces invoice CZN000014394 _ Subtotal: 386.863.79 AMOUNT DUE: 386,863.79 Please Remit To: EFT Payment To: Corizon Health, Inc. Account Number: 000112997168 12464 Collection Center Drive Routing Number: 064000020 Chicago IL 60693 Please Document Any Variations In Amounts Not Paid in Full Corizon Health Invoice for Contract Year 2013 Okaloosa County, FL Aggregate Report for Contract Year: October 1, 2012 through September 30, 2013 Aggregate Terms per Contract (backup attached): Annual Aggregate Limit: 500,000.00 If > $500,000 but < $1,242,000 County to pay Corizon 20% of difference between $1,242,000 and actual 500,000.00 Summary of Aggregate Calculation through 02/27/14 Paid Claims 533,297.37 Pharmacy 264,782.37 Total Paid through 02/24/11: 798,079.74 Yearly Aggregate Limit (Corizon Health responsibility) : 500,000.00 Total Corizon Health responsibility as of 02/27/14: 500,000.00 Amount in excess of Corizon Health responsibility 298,079.74 Plus: 20% Reimb to Corizon if yearly amount is greater than $500,000 but less than $1,242,000 88,784.05 Total amount due from County 386,863.79 Less: Previous invoicing related to current contract year [Total amunt due this invoice