Velcro High-Cost Claimants Large Claim Listing VELCRO USA INC. Effective 01/01/2022 Claimants with over $50,000 in claims for 01/01/2022 -12/31/2022 $210,000 Claimant RelationshipStatus Plan Oct. Nov. Dec. ICD-9 Code Description Reimbursement Claimant 1 SP Active HSA $ 355,706 $ 361,463 $ 372,115 TYPE 2 DIABETES W DIABETIC PERIPHERAL ANGIOPATHY W GANGRENE $162,115 Claimant 2 EE Active HRA $ 218,797 $ 247,553 $ 279,486 END STAGE RENAL DISEASE $69,486 Claimant 3 SP Active HRA $ 203,640 $ 235,241 $ 254,796 TRAUM SUBRAC HEM W/O LOSS OF CONSCIOUSNESS, INIT $44,796 Claimant 4 EE COBRA HRA $ 208,171 $ 225,507 $ 244,177 MULTIPLE MYELOMA NOT HAVING ACHIEVED REMISSION $34,177 Claimant 5 EE Active HSA $ 161,807 $ 177,952 $ 194,451 CHRONIC LYMPHOCYTIC LEUK OF B-CELL TYPE NOT ACHIEVE REMIS Claimant 6 EE Active HSA $ 176,163 $ 177,842 $ 179,446 INFECT/INFLM REACTION DUE TO INTERNAL RIGHT HIP PROSTH, INIT Claimant 7 EE Active HRA $ 131,609 $ 172,645 $ 173,429 UNSP FRACTURE OF NAVICULAR BONE OF RIGHT WRIST, INIT Claimant 8 EE Active HRA $ 119,111 $ 119,865 $ 125,540 SECONDARY MALIGNANT NEOPLASM OF BRAIN Claimant 9 EE Active HRA $ 88,092 $ 123,115 MALIGNANT NEOPLASM OF TRIGONE OF BLADDER Claimant 10EE Active HSA $ 111,679 $ 112,493 $ 117,249 MALIGNANT NEOPLASM OF LOWER LOBE, LEFT BRONCHUS OR LUNG Claimant 11EE Active HRA $ 110,155 $ 114,293 $ 115,250 MALIGNANT NEOPLASM OF CECUM Claimant 12EE Active HSA $ 115,005 OTHER SEQUELAE OF NONTRAUMATIC INTRACEREBRAL HEMORRHAGE Claimant 13CH Active HSA $ 109,155 $ 110,474 $ 111,184 ARNOLD-CHIARI SYNDROME WITH SPINA BIFIDA AND HYDROCEPHALUS Claimant 14SP Active HRA $ 97,949 $ 98,508 $ 104,188 NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION Claimant 15SP Active HRA $ 95,428 $ 101,078 $ 101,985 STEMI INVOLVING OTH CORONARY ARTERY OF ANTERIOR WALL Claimant 16EE Active HRA $ 75,096 $ 99,972 $ 99,972 MULTIPLE SCLEROSIS Claimant 17SP Active HSA $ 67,864 $ 98,465 $ 99,035 ACUTE CHOLECYSTITIS Claimant 18SP Active HSA $ 93,324 $ 93,551 $ 96,367 INTERVERTEBRAL DISC DISORDERS W RADICULOPATHY, LUMBAR REGION Claimant 19EE Terminated HRA $ 91,173 $ 91,173 $ 90,724 OTHER MALAISE ` Claimant 20SP Active HSA $ 53,962 $ 78,538 $ 88,734 POLYP OF CORPUS UTERI Claimant 21CH Active HSA $ 80,515 $ 88,225 $ 88,603 COMPRESSION OF BRAIN Claimant 22SP Active HSA $ 61,620 $ 61,963 $ 82,326 ULCERATIVE COLITIS, UNSPECIFIED, WITHOUT COMPLICATIONS Claimant 23CH Active HSA $ 75,598 $ 80,283 $ 81,099 LOCAL-REL SYMPTC EPI W CMPLX PART SEIZ, NTRCT, W/O STAT EPI Claimant 24SP Active HSA $ 76,488 $ 76,488 $ 76,488 INTERVERTEBRAL DISC DISORDERS W MYELOPATHY, THORACIC REGION Claimant 25EE Active HSA $ 68,048 $ 73,473 $ 74,175 MULTIPLE SCLEROSIS Claimant 26SP Active HSA $ 58,806 $ 62,636 $ 70,476 NON-PRS CHRONIC ULC UNSP PRT OF L LOW LEG W UNSP SEVERITY Claimant 27EE Terminated HRA $ 70,009 END STAGE RENAL DISEASE Claimant 28CH Terminated HSA $ 61,161 $ 61,161 $ 61,161 OTHER SPECIFIED JOINT DISORDERS, RIGHT HIP Claimant 29SP Active HSA $ 59,161 $ 59,506 $ 60,898 TYPE 2 DIABETES MELLITUS WITH FOOT ULCER Claimant 30SP Active HSA $ 53,102 $ 56,253 $ 59,364 UTEROVAGINAL PROLAPSE, UNSPECIFIED Claimant 31SP Active HSA $ 55,958 $ 57,767 PNEUMONIA, UNSPECIFIED ORGANISM Claimant 32SP Active HSA $ 55,009 $ 55,924 $ 56,274 TYPE 2 DIABTES MELLITUS WITH HYPOGLYCEMIA WITHOUT COMA Claimant 33SP Active HSA $ 53,036 $ 53,352 $ 55,529 UNILATERAL PRIMARY OSTEOARTHRITIS, LEFT HIP Claimant 34SP Active HSA $ 51,540 $ 51,815 $ 52,114 DIAPHRAGMATIC HERNIA WITHOUT OBSTRUCTION OR GANGRENE Total $ 3,234,874 $ 3,641,741 $4,032,527 $ 310,574 $ 6,815,397 $ 7,693,439 $ 8,369,285 Total Paid Claims (gross) 47.5% 47.3% 48.2%High Claimants / Total Paid Claims 2023 Specific Stop Loss Deductible is $210,000 (Symetra is reinsurer) 47