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Home My WebLink About14-7203 Supreme Cal,", nnsylvania Cour' &COMnrao Pleas For Prothonotary Use Only: Docket No: Ctiffibjeffi County The iqforntation collected on this form is used solely for court administration purposes. This form does not supplement or replace thefiling and sen,ice of pleadings or other papers as required by law or rules qfcourt. Commencement of Action: S na, Complaint 0 Writ of Summons Petition 0 Transfer from Another Jurisdiction [3 Declaration of Taking E C Lead Plaintiff-s Name: Lead Defendant's Name: T Pennsylvania Employee Benefit Trust Fund Amy Nolan Dollar Amount Requested: Owithin arbitration limits Are money damages requested? M Yes 0 No (check one) Routside arbitration limits 0 N Is this a Class Action Suit? [3 Yes No Is this an MDJAppeal? E3 Yes 0 No Name of Plaintiff/Appellant's Attorney: Michael J.Leffey Esq. 0 Check here if you have no attorney(are a Self-Represented [Pro Se] Litigant) Nature of the Case: Place an"X"to the left of the ONE case category that most accurately describes your ► PRIMARY CASE. If you are making more than one type of claim,check the one that you consider most important. TORT(do not incinde mass Tort) CONTRACT(do not include Judgments} CIVIL APPEALS Intentional El Buyer Plaintiff Administrative Agencies n Malicious Prosecution 0 Debt Collection:Credit Card 0 Board of Assessment 0 Motor Vehicle IN Debt Collection:Other 0 Board of Elections [3 Nuisance Health Benefits n Dept.of Transportation [3 Premises Liability [3 Statutory Appeal:Other S M Product Liability(does not include Mass fort) Employment Dispute: E E3 Slander/Libel/Defamation Discrimination C Other: Employment Dispute:Other [3 Zoning Board n T ® Other: n Other: Q MASS TORT 0 Asbestos N f7l Tobacco Toxic Tort-DES F71 Toxic Tort-Implant REAL PROPERTY MISCELLANEOUS [j Toxic Waste 0 Ejectment [] Common Law/Statutory Arbitration B n Other: El Eminent Domain/Condemnation ® Declaratory Judgment 0 Ground Rent n Mandamus n Landlord/Tenant Dispute [3 Non-Domestic Relations [3 Mortgage Foreclosure:Residential Restraining Order PROFESSIONAL LIABLITY nj Mortgage Foreclosure:Commercial 0 Quo Warranto 0 Dental rl Partition 0 Replevin El Legal Quiet Title 13 Other: 0 Medical Other: E] Other Professional: Updated 11112011 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,PENNSYLVANIA Pennsylvania Employee Benefit Trust fund Plaintiff vs Amy Nolan �T,_ : , . . Defendant NOTICE TO DEFEND YOU HAVE BEEN SUED IN COURT. IF YOU WISH TO DEFEND AGAINST THE CLAIMS SET FORTH IN THE FOLLOWING PAGES,YOU MUST TAKE ACTION-WITHIN TWENTY (20) DAYS AFTER THIS COMPLAINT AND NOTICE ARE SERVED, BY ENTERING A WRITTEN APPEARANCE PERSONALLY OR BY AN ATTORNEY AND FILING IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. YOU ARE WARNED THAT IF YOU FAIL TO DO SO THE CASE MAY PROCEED WITHOUT YOU AND A JUDGMENT MAY BE ENTERED AGAINST YOU BY THE COURT WITHOUT FURTHER NOTICE FOR ANY MONEY CLAIMED IN THE COMPLAINT OR FOR ANY OTHER CLAIM OR RELIEF REQUESTED BY THE PLAINTIFF. YOU MAY LOSE MONEY OR PROPERTY OR OTHER RIGHTS IMPORTANT TO YOU. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUECED FEE OR NO FEE. CUMBERLAND COUNTY BAR ASSOCIATION 32 SOUTH BEDFORD STREET CARLISLE,PA 17013 1-800-990-9108 717-249-3166 (��)5 � �, � 5c) c� IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA PENNSYLVANIA EMPLOYEES ) CIVIL DIVISION BENEFIT TRUST FUND ) No.. Plaintiff, ) TYPE OF PLEADING: V. ) COMPLAINT IN CIVIL ACTION Amy Nolan FILED ON BEHALF OF Defendant. ) PLAINTIFF COUNSEL OF RECORD FOR THIS PARTY: Michael J. Laffey, Esquire Pa. I.D. No.: 47246 Laffey &Associates, P.0 415 Chartiers Avenue Pittsburgh, PA 15106 (412) 429-7079 1 Cumberland County Court of Common Pleas Pennsylvania Employees Benefit Trust Fund, Plaintiff, Civil Case No.: VS. Complaint in Civil Action Amy Nolan, 1105 E. Powderhorn Road Mechanicsburg PA 17050-2003 Defendant COMPLAINT IN CIVIL ACTION AND NOW comes plaintiff, Pennsylvania Employees Benefit Trust Fund, by its undersigned counsel Michael J. Laffey, and complains against defendant, Amy Nolan, as follows: 1. Plaintiff Pennsylvania Employees Benefit Trust Fund (hereinafter "Plaintiff') is an Employee Benefit Trust Fund organized under the laws of the Commonwealth of Pennsylvania. It maintains a place of business at 150 South 43rd Street, Suite 1 in Harrisburg, Pennsylvania 17111-5700. 2 2. Amy Nolan, Defendant herein (hereinafter"Defendant"), is an individual,residing at 1105 E Powderhorn Road, Mechanicsburg, Pennsylvania, 17050-2003 3. During the time periods of; (4/5/11 thru 4/11/11) , (5/11/11 thru 5/23/11) , (6/14/11 thru 9/21/11) , (10/4/11 thru 10/26/11). Defendant was placed on leave without pay with benefits. During this period, the plaintiff conferred $73,405.14 in medical payments on behalf of the defendant. 4. During the time period of(11/15/11 thru 11/26/11) , Defendant was placed on leave without pay without benefits. During this period, the plaintiff conferred $18,606.02 in medical payments on behalf of the defendant. 5. For the period of(11/15/11 thru 11/26/11), Defendant was placed on COBRA. During this period,the Plaintiff conferred$10,904.17 in medical payments on behalf of the defendant. 6. During the relevant periods Defendant has failed to pay her contractually required individual healthcare contributions. 7. Plaintiff has made numerous attempts to collect the employee contributions which have not been received. 8. Defendant's willful failure to pay constitutes a breach of the contract between Plaintiff and Defendant. 9. Plaintiff has terminated Defendants eligibility back to the period when benefits were paid. 3 COUNT I BREACH OF CONTRACT 10. Defendant as a requirement to receive entitlement to benefits is required to make mandatory health benefit plan contributions. (Benefits Contract at Sec. 1.14, (Exhibit A). 11. Defendant has failed to make required mandatory contributions and Plaintiff therefore, In accordance with section 1.27 of the plan, concerning use of benefits following eligibility, Plaintiff demands repayment of $102,915.33 in benefits paid following expiration of eligibility. 12. Defendant has received $102,915.33 in medical benefit payments to which he is not entitled by failing to make required payments. WHEREFORE, Plaintiff, (PEBTF), respectfully requests this Honorable Court to issue an Order: (a) Granting judgment for Plaintiff and against Defendant Amy Nolan in the amount of $102,915.33, exclusive of interest and costs; which represents the Medical Claims Paid by the Plaintiff as itemized in (exhibit B) to which Defendant was not entitled because of her failure to make her required co-payments. (b) Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action; and (c) Granting such other relief as the Court deems appropriate. 4 COUNT II UNJUST ENRICHMENT 13. The allegations of Paragraphs 1 through 12, above, are incorporated herein by reference as if fully set forth. 14. Defendant received medical services, paid for by the plaintiff, and received the benefit thereof. The cumulative amount paid by the plaintiff is $102,915.33. An attached Itemized list of claims paid by the plaintiff on behalf of the defendant is attached as (exhibit B). 15. Defendant has neglected and continues to refuse to reimburse Plaintiff for such services. 16. Defendant, having breached the terms of her benefit agreement, has been unjustly enriched by the Plaintiff to the extent of$102,915.33 in Medical Benefits incurred by the Defendant to the providers listed in Exhibit B. WHEREFORE, plaintiff, PEBTF,respectfully requests this Honorable Court to issue an Order: (a) Granting judgment for Plaintiff and against Defendant Amy Nolan in the amount of $102,915.33, exclusive of interest and costs; (b) Granting Plaintiff its expenses, including reasonable attorney fees incurred in connection with this action; and 5 (c) Granting such other relief as the Court deems appropriate. Respectfully submitted, Laffe4& sociales By: Michael J. Laffey PA I.D. No.:47246 415 Chartiers Ave Carnegie, PA 15106 412-429-7079 Attorney for Plaintiff 6 VERIFICATION AFFIDAVIT I verify that the statements made herein are true and correct to the best of my knowledge, information, and belief I understand that false statements herein are made subject to the penalties of Pa. C.S., §4904,relating to unsworn falsifications to authorities. Date: Id/I6 .41-�191 Michael J Laffey, Laffey &Associates P.C Carnegie, Pa 15106 Exhibit A PENNSYLVANIA EMPLOYEES BENEFIT TRUST FUND MEDICAL PLAN PLAN DOCUMENT as amended and restated effective January 1, 2011 OMEAST#13082487 V3 the Trustees and signed by an individual authorized to sign on behalf of the Trustees. No such written waiver shall be deemed a continuing waiver unless specifically stated therein, and each such waiver shall operate only as to the specific term or condition waived and shall not constitute a waiver of such term or condition for the fi>ture or as to any act other than the one specifically waived. Neither the Executive Director nor any other employee of the Fund shall have the authority to alter, change, amend, or waive any provision of the Plan or any rules or regulations relating thereto, whether orally or in writing, and any such alteration, change, amendment or waiver shall be null and void in all respects. 1.13 Exclusive Rights No individual shall have a right to benefits provided under the Plan, except as specified herein; and in no event shall any right to benefits under the Plan be vested. No party shall be bound to, or shall be able to rely upon, any oral representations about the contents of this Plan that are inconsistent with the terms of the Plan, and any such representations shall be null and void in all respects. 1.14 Contributions to the Fund Benefits payable under this Plan are payable only to the extent funded by means of contributions to the Trust Fund by the participating Employers,participating Employer health and welfare trust Rinds, or, in some cases, individual employees (on their own behalf or from other sources on their behalf)who have self-paid or partially self-paid coverage under the Plan. All contributions are made pursuant to the relevant collective bargaining agreements and/or participation agreements with the Trust Fund,and in accordance with the Agreement and Declaration of Trust. (Self-paid continuation coverage known as "COBRA" coverage, and surviving dependent coverage,are discussed in Article XII herein.) 1.15 Supplemental Benefits Supplemental benefits include prescription drug, dental, vision and hearing aid benefits. Unless otherwise specified by the relevant collective bargaining agreement or participation agreement, or as otherwise set forth in Article III, employees who are eligible for medical/surgical benefits under the Plan are also eligible for supplemental benefits under the Plan pursuant to the same eligibility rules that apply to medical/surgical benefits. To the extent that employees' eligibility for supplemental benefits differs from their eligibility for medical/surgical benefits, the contribittions to the PEBTF will be specified in the relevant collective bargaining agreement or. participation agreement. 1.16 Return of Overpayments/Erroneous Payments Payments made in error shall be returned to the Trust Fund by the recipient. The Fund may deduct the amount of such erroneous payments or overpayments from any subsequent benefits payable to or for the Member or from other present or firture amounts payable, or the Fund may recover such amount(s) by any other lawful method it deems appropriate. See also Section 1.26. DMEAST#13082487 Y3 4 ARTICLE 1-GENERAL PROVISIONS i 1.24 Workers' Compensation The benefits provided by the Plan are not in lieu of, and do not affect any requirement for, coverage by a Workers' Compensation law or similar legislation. Plan benefits are not payable for any Injury or Illness suffered by a Member for which there is coverage under any applicable workers' compensation law or Occupational disease law. Employee Members who have Workers' Compensation claims, which resulted from Commonwealth employment, may be required to use their prescription drug card to obtain medications used for work-related injuries. . 1.25 Veterans Administration Claims If a Member receives services at a Veterans Administration (VA) hospital or outpatient facility for a non-service related Injury or Illness,the VA can submit a claim to the proper claims payor for the amount that would have been paid if the Member were not treated in a VA facility. Federal Law requires that payment go directly to the VA facility. The Member will receive an Explanation of Benefits (EOB) when these claims have been processed. If a Member receives any payment from the claims payor in error, the Member is required to submit it directlto the VA facility. See Section 1.26. y 1,26 Payments Made In Error In the event that the PEBTF or a Claims Payor makes any payment to the Member or the Member's dependents,or on the Member's or the Member's dependents' behalf, which are made in error, the PEBTF or the Claims Payor shall have the right to recoup the payment from the Member or, at its option, to deduct the payment from future payments to which the Member may be entitled or which might otherwise be payable on the Member's or the Member's dependents' behalf. Should the Member fail to repay the money, the Member and the Member's dependents will be ineligible for all future benefits until the money is repaid in full, or until the PEBTF receives the initial repayment in accordance with the terms of a voluntary repayment plan agreed to between the Member and the PEBTF. Such repayment plan shall contain such terms and conditions as the PEBTF may require. However, in the event the Member should fail to make a timely payment under the repayment plan,the PEBTF may suspend coverage, effective as of the paid-through date, for the Member and Member's dependents, and the Member (and the Member's dependents) shall thereafter be ineligible for all future benefits until the entire amount owed to the PEBTF is repaid in full, and for six (6) months thereafter. The Member may appeal any demand for repayment or suspension of coverage described in this Section by filing an appeal with the Board of Trustees. Such appeal should be in writing and postmarked to the PEBTF within 60 days of the demand for repayment or notification of suspension. See also Section 1.16. .1.27 Use of Benefits Following Expiration of Eligibility In the event that the Plan pays benefits for the expenses of an individual who was covered under the Plan as the Dependent of an Employee Member, when those expenses are incurred after that individual ceases to be eligible for coverage as the Employee Member's Dependent and at a time when the individual is not otherwise covered tinder the Plan, the Employee Member shall be required to repay the PEBTF the full amount of such benefits within sixty days of the date that OMEAST#13082487 V3 12 ARTICLE I-GENERAL PROVISIONS the Employee Member is notified of the amount due, unless alternative repayment arrangements are made with the PEBTF in accordance with the provisions of this Section. Should the Member fail to repay the money, the Member and all of the Member's dependents will be ineligible for future benefits (provided the individual is otherwise eligible for coverage) until the date the money is repaid in full, or until the PEBTF receives the initial repayment in accordance with a voluntary repayment plan agreed to between the Member and the PEBTF. Such repayment plan shall contain such terms and conditions as the PEBTF may require. However, in the event the Member should fail to make a timely payment under the repayment plan, the PEBTF may suspend coverage, effective as of the paid-through date, for the Member and the Member's dependents, and the Member(and the Member's dependents)shall thereafter be ineligible for all fixture benefits until the entire amount owed to the PEBTF is repaid in full, and for six (6) months thereafter. The ,Member may appeal any demand for repayment or suspension of coverage described in this Section by filing an appeal with the Board of Trustees. Stich appeal must be in writing and postmarked to the PEBTF within 60 days of the demand for repayment or notification of suspension. 1.28 Dlselaimer None of the benefits provided under the Plan is guaranteed by the Board of Trustees, any Employer,Union or other individual or entity. Benefits may be provided only from assets of the Fund collected and available for such purpose. 1.29 Time Limits Throughout this document, there are provisions regarding time limits for filing claims and appeals, paying COBRA premiums, and notifying the PEBTF. These time limits must be strictly adhered to in compliance with the terms of the Plan. 1.30 Common Law Marria es On September 17, 2003, the Pennsylvania Commonwealth Court ruled that it will no longer recognize common law marriage in Pennsylvania.In addition,effective January 24,2005,23 Pa. C.S.A. Domestic Relations section 1103 was revised such that common law marriages entered into after January 1, 2005, in Pennsylvania will not be recognized. Moreover Pennsylvania has never recognized common law divorce. If an Employee Member has previously listed an individual as a common law spouse and subsequently seeks to remove the individual from coverage, the Employee Member will not be permitted to subsequently add another person as a spouse, (even with a marriage certificate) without first producing a valid divorce decree from a court of competent jurisdiction certifying the divorce from the prior common law spouse. There are no exceptions to this rule. If an Employee Member and a common law spouse live in a state other than Pennsylvania, it must be a state which recognizes common law marriage for the parties to have a valid common law marriage and enroll the spouse in PEBTF coverage. If there is not a valid common law marriage in that state, the Employee Member may not enroll the intended"spouse"as a"dependent spouse"for coverage under the PIan. Employee Members who entered into common law marriage in Pennsylvania prior to September 17, 2003, and would like to obtain coverage for a ,common law spouse will be DMEAST#13082487 V3 13 ARTICLE 1-GENERAL PROVISIONS Exhibit B Amy Nolan PEBTF Claim Untilization Summary Assignment#:52760 Services Start Date End Date Total Amount Paid Claims Utilization 11/15/2011 11/26/2011 $18,588.64 Rx Claims Utilization 10/4/2011 10/25/2011 $1,376.42 Claims Utilization 6/14/2011 9/20/2011 $ Claims Utilization 5/11/2011 5/22/2011 5 $77,,409.409.95 Rx Claims Utilization 5/11/2011 5/22/2011 $252.12 Claims Utilization 10/4/2011 10/25/2011 $8,966.67 Rx Claims Utilization 6/14/2011 9/20/2011 $6,819.27 Claims Utilization 3/6/2012 4/22/2012 $9,844.51 Rx Claims Utilization 3/6/2012 4/22/2012 $1,059.66 Rx Claims Utilization 11/15/2011 11/26/2011 $17.38 Total Paid $102,915.33 PROGRAM: P9/05/2 Penns Pennsylvania Em to ee Benefit Trust Fund_ DATE: 9/05/12 � ' -_ aims a sza ion TIME: 9:58:07 Member Number PAGE: 1 Member Name NDC NABP Rx NBR Fill Date Group AMY � D/SupCo-Pa05 y Person 5901 OLAN Bil� 1 Amount Fu Number: 29 2011112/14 ACT? 01 AMY OLAN $18.00 $1,065.56 0000 Fu Number: 30 2011/10/06 CT? 01 A 30 30 ' AMY OLAN $10.00 $2.13 0009 65 2011/10/07 Fu Number: 60 30 ACT? 01 AMY OLAN $10.00 $13.07 0037 66 2011/10/07 Fu Number: 120 30 ACT. 01 AMY OLAN $10.00 $22.62 0037 66 2011/10/07 Fu Number: 120 30 ACT' 01 AMY OLAN $10.00- $22.62- 5901 /10/24 ACT?30 15 Fu Number: 29 2011 • $18.00 $2 01 AMY OLAN $273.04 0052 27 2011/10/24 Fu Number: 30 15 ACT. 01 AMY OLAN $7.94 0037 .FU Number: 66 2011/10/24 ACT? Fu . 01 120 30 $10.00 $22.62 Total Number of Rx Claims - Total Value of RX Claims From 2011/10/04 thru 2011/10/25 - $1,376.42 ** END OF REPORT ** Exhibit B Report ID: PUR9080R PEBTF Claims Utilization Page: 1 P00043-001 Report Period I1/15/11 11/26/11 Subscriber Run Date: 9/07/12 S:14:55 Selected By CGOLDA Name DOS Diag Cd. Procedure Net Amounti* Indicates Discount Applied NOLAN, AMY Provider Claim # 20111115 File/Plan Group Inv. Date NOLAN, AMY 20111115 45.00 NOLAN, AMY 20111115 3.11 HMK/055 2011/11/23 NOLAN, AMY 20111115 200.00 HMK/055 2011/11/2355 2011/12/07 NOLAN, AMY 20111115 51.98 HMR/0 NOLAN, Amy NOLAN, AMY 20111115 139.23 HMK/055 2011/12/07 20111115 49.14 HMK/055 NOLAN, AMX NOLAN, AMY 201111 2011/12/07 15 18.08 HMK/055 2011/12/07 , AMY 20111115 12.60 MK/ 2011/12/07 NOLAN NOLAN, AMY 20111115 112.77 HMK/055 2011/12/07 20111115 47.88 HMR/055 20111115 93.87 KMK/055 2011/12/07 NOLAN, AMY NOLAN, Amy 20111115 148.0.5 2011/12/07 NOLAN, AMY HMK/055 2011/12/07 NOLAN, AMY 20111115 76.23 HMK/055 2011/12/07 NOLAN, AMY 20111115 925.87 HMK/055 2011/12/07 NOLAN, ANY 20111115 10.02 HMK/055 2011/12/07 NOLAN, AMY 20111115 3.28 HMK/055 2011/12/07 NOLAN, AMY 20111117 2.74 HMR/055 2011/12/07 NOLAN, 20111117 51.98 HMK/0552011/ 12/07 HMR/055 NOLAN, AMY 20111117 139.23 2011/12/07 NOLAN, AMY 20111117 49.14 HMR/055 2011/12/07 NOLAN, AMY 20111117 18.08 MK/055 2011/12/07 17 NOLAN AMY 20111117 22.68 HMK/055 2011/12/07 NOLAN, AMY 20111117 '55 HMR/055 2011/12/07 NOLAN, Amy 20111117 65.52 HMR/055 NOLAN, AMY 2011/12/07 20111117 3,294.67 HMK/055 2011/12/07 20111117 975.87 HMK/055 NOLAN, Amy 20111117 10.02 HMR055 2011/12/07 NOLAN, Amy 2011/12/07 . NOLAN, AMHMK/055 Y 20111117 3.28 2011/12/07 NOLAN, Amy 20111117 2.74 HMR/055 2011/12/07 NOLAN, AMY 20111117 86.12 HMK/ass 2011/12/07 NOLAN, Amy 20111118 200.00 HMK/055 2011/12/07 , 20111118 43.44 HMK/055 2011/12/28 NOLANAmy 20111118 112.77 HMK/055 2011/12/07 NOLAN, Amy NOLAN, Amy 20111118 209.16 HMK/055 2011/12/07 NOLAN, Amy 20111119 76.23 HMK/055 2011/12/07 NOLAN, Amy 20111119 103.95 HMK/055 2011/12/07 NOLAN, Amy 20111119 278.46 HMK/055 2011/12/07 NOLAN, Amy 20111119 18.08 HMK/055 2011/12/07 NOLAN, AMY 20111119 12.60 HMK/055 2011/12/07 NOLAN, Amy 20111119 112.77 HMK/055 2011/12/07 NOLAN, Amy 20111119 47.88 HMK/055 2011/12/07 NOLAN, AMY 20111119 93.87 HMK/055 2011/12/07 NOLAN, AMY 20111119 148.05 HMK/055 2011/12/07 NOLAN, Amy 20111119 76.23 HMK/055 2011/12/07 NOLAN, Amy 20111119 423.99 HMK/055 2011/12/07 NOLAN, AMY 20111119 575.59 HMK/055 2011/12/07 20111119 10.02 HMK/055 2011/12/07 9.83 HMK/055 2011/12/07 HMK/055 2011/12/07 Report ID; PUR9080R PEBTF Claims Utilization_ Page: 2 P00043-001 Report Period 11/15/11 11/26/11 Subscriber Run Date: 9/07/12 8:14:55 Selected By CGOLDA Name DOS Dia Cd. ** Indicates Discount g Procedure Net Amount Applied NOLAN, AMY Provider NOLAN, AMY 20111119 Claim # NOLAN, AMY 20111119 File/plan Group Inv. Date 33.00 NOLAN, AMY 20111121 200.00 20111121 6000 HMK/055 2011/12/07 NOLAN, AMY . RMK/055 2011/12/07 NOLAN ANY 20111121 28.50 HMK/055 2011/12/07 NOLAN, Amy 20111121 86.12 HMK/055 2011/12/07 NOLAN, AMY 20111121 200.00 HMK/Os-5 2011/12 NOLAN, AMy 20111121 385.00 HMR/055 2011/12/14 NOLAN AMY 20111121 61.83 HMK/055 2011/12/14 NOLAN, AMY 20111121 100.00 HMK/055 2011/12/14 NOLAN, AMY 20111122 61811.21 HMK/055 2011/12/14 NOLAN, AMY 20111123 75.00 HMK/055 2011/12/14 NOLAN, AMY 20111123 24.00 HMK/055 2011/12/14 NOLAN, AMY 20111123 75.00 HMR/055 2011/12/14 NOLAN, AMY 20111123 260.00 HMR/055 2011/12/14 NOLAN, Amy 20111123 256.50 HMK/055 2011/12/14 NOLAN, AMY 20111124 256.50 HMK/USS 2011/12/14 NOLAN, AMY 20211124 56.00 HMK/055 NOLAN, AMY 20111125 75.00 2011/12/28HMK/055 2011/12/14 NOLAN, AMY 20111125 135.00 20111126 75.00 HMK/055 2011/12/14 75.00 HMR/055 2011/12/07 HMK/055 2011/22/14 HMK/055 2011/12/14 Total Amount 18,588.64 Report ID: PUR9080R PEBTF Claims Utilization Page: 1 P00043-001 Report Period 6/14/11 9/20/11 Run Date: 9/07/12 8:14:28 Subscriber ® Selected By CGOTDA indicates +�* indicates Discount Applied Name DOS Diag Cd. Procedure Net Amount Provider Claim # Pile/Plan Group Inv. Date NOLAN, AMY 20110614 1.76 HMK/055 2011/12/28 NOLAN, AMY 20110625 1.08 WK/055 2011/12/28 NOLAN, AMY 20110625 3.63 HMK/055 2011/12/28 NOLAN, ANY 2011061459.09 HMK/055 2011/06/29 NOLAN, AMY 20110614 131.67 HMK/055 2011/06/29 NOLAN, AMY 20110614 46.62 HMK/055 2011/06/29 NOLAN, AMY 20110614 11.97 HMR/055 2011/06/29 HMK/055 2011/06/29 NOLAN, AMY 20110614 106.47 NOLAN, AMY 20110614 45.36 HMK/055 2011/06/29 NOLAN, AMY 20110614 88.83 HMK/055 2011/06/29 NOLAN, AMY 20110614 139.86 HMK/055 2013/06/29 NOLAN, AMY 20110614 46.62 HMK/055 2011/06/29 NOLAN, AMY 20110614 72.45 HMK/055 2011/06/29 NOLAN, AMY 20110614 62.37 HMR/055 2011/06/29 NOLAN, AMY 20110614 632.52 HMK/055 2011/06/29 NOLAN, AMY 20110614 871.06 HMK/055 2011/06/29 NOLAN, AMY 20110614 5.01 HMK/055 2011/06/29 NOLAN, AMY 2011.0614 4.25 HMK/055 2011/06/29 NOLAN, AMY 20110614 5.26 HMK/055 2011/06/29 NOLAN, AMY 20110614 3.28 HMK/055 2011/06/29 NOLAN, AMY 20110614 38.00 HMK/055 2011/07/06 NOLAN, AMY 20110614 190.00 KKK/055 2011/09/21 NOLAN, AMY 20110620 51.98 HMK/055 2011/07/06 NOLAN, AMY 20110620 131.67 HMK/055 2011/07/06 NOLAN, AMY 20110620 18.08 HMR/055 2011/07/06 NOLAN, AMY 20110620 11.97 HMK/055 2011/07/06 NOLAN, AMY 20110620 106.47 HMK/055 2011/07/06 NOLAN, ANY 20110620 45.36 HMK/055 2011/07/06 NOLAN, AMY 20110620 72.45 HMK/055 2011/07/06 NOLAN, AMY 20110620 3,105.67 HMK/055 2011/07/06 NOLAN, AMY 20110620 56.70 HMK/055 2011/07/06 NOLAN, AMY 20110620 1,230.39 HMK/055 2011/07/06 NOLAN, AMY 20110620 10.02 HMK/055 2011/07/06 NOLAN, AMY 20110620 6.55 HMR/055 2011/07/06 NOLAN, AMY 20110620 83.85 HMK/055 2011/07/06 NOLAN, AMY 20110620 135.00 HMK/055 2011/07/06 NOLAN, AMY 20110621 60.00 HMK/055 2011/07/06 HMK/055 2011/07/06 NOLAN, AMY 20110621 60.00 HMK/055 2011/07/13 NOLAN, AMY 20110621 .29 HMK/055 2011/07/13 NOLAN, AMY 20110621 5.13 HMK/055 2011/07/13 NOLAN, AMY 20110621 42.75 NOLAN, AMY 20110621 13.11 HMK/055 2011/07/13 NOLAN, AMY 20110621 118.28 HMK/055 2011/07/13 NOLAN, AMY 20110621 193.52 HMR/055 2011/07/13 NOLAN, AMY 20110621 74.10 HMK/055 2011/07/13 NOLAN, AMY 20110621 60.00 HMR/055 2011/07/13 NOLAN, AMY 20110624 65.50 HMR/055 2011/07/13 NOLAN, AMY 20110624 54.15 HMR/OSS 2011/07/20 - ------,....... _ _._... .. .. ........ Report TD: PUR9080R PEBTF Claims Utilization Page. 2 P00043-001 Report Period 6/14/11 9/20/11 Run Date: 9/07/12 8:14:28 Subscriber - Selected By CGOLDA +* indicates Discount Applied Name DOS Diag Cd. Procedure Net Amount Provider claim # File/Plan Group Inv. Date NOLAN, AMY 20110624 7.98 HMK/055 2011/07/20 NOLAN, AMY 20110624 .86 HMK/055 2011/07/20 NOLAN, AMY 20110624 55.01 HMK/055 2011/07/20 NOLAN, AMY 20110624 33.06 HMR/055 2011/07/20 HMR/055 2011/07/20 NOLAN, AMY 20110624 12.26 HMK/055 2011/07/20 NOLAN, AMY 20110624 2.00 24 19.95 HMR/055 2011/07/20 NOLAN, AMY 201106 NOLAN, AMY 20110624 57.00 HMK/055 2011/07/20HMK/055 2011/07/20 NOLAN, AMY 20110624 20.24 HMK/055 2011/07/20 NOLAN, AMY 20110624 230.85 HMR/055 2011/07/20 NOLAN, AMY 20110624 619.02 HMK/055 2011/07/20 NOLAN, AMY 20110624 131.10 HMK/055 2011/07/20 NOLAN, AMY 20110624 1.71 HMK/055 2011/07/20 NOLAN, AMY 20110624 1.43 HMK/055 2011/07/20 NOLAN, AMY 20110624 6.56 HMK/055 2011/07/20 NOLAN, AMY 20110624 23.37 HMK/055 2011/07/20 NOLAN, AMY 20110624 115.71 HMR/055 2012/05/09 NOLAN, AMY 20110624 192.50 HMK/055 2012/05/09 NOLAN, AMY 20110624 192.50 HMR/055 2011/07/13 NOLAN, AMY 20110625 131.67 NOLAN, AMY 20110625 11.97 HMK/055 2011/07/13 NOLAN, AMY 20110625 106.47 HMK/055 2011/07/13 NOLAN, AMY 20110625 45.36 HMR/055 2011/07/13 NOLAN, AMY 20110625 46.62 HMK/055 2011/07/13 NOLAN, AMY 20110625 72.45 HMK/055 2011/07/13 NOLAN, AMY 20110625 113.40 HMK/055 2011/07/13 NOLAN, AMY 20110625 871.06 MK/055 2011/07/13 NOLAN, AMY 20110625 10.02 HMK/055 2011/07/13 HMK/055 2011/07/13 NOLAN, AMY 20110625 6,243.03 HM/055 2011/07/13 NOLAN, AMY 20110625 190.00 NOLAN, AMY 20110702 86.12 HMK/055 2011/07/20 NOLAN, AMY 20110702 67.00 HMR/055 2011/07/20 HMK/055 2011/07/20 NOLAN, AMY 20110702 15.00 HMR/055 2011/07/20 NOLAN, AMY 20110702 12.00 NOLAN, AMY 20110702 200.00 HMK/055 2011/07/11 NOLAN, AMY20110702 15.00 HMR/055 2011/07/11 NOLAN, AMY 20110702 .63 HMK/055 2011/07/11 NOLAN, AMY 20110702 17.48 HMR/055 2011/07/11 HMR/055 2011/07/11 NOLAN, AMY 20110702 150.63 HMK/055 2011/07/11 NOLAN, AMY 20110702 355.32 98 2a HMK/OSs 2011/07/11 NOLAN, AMY 20110702 NOLAN, AMY 20110702 36.16 HMK/oss 2011/07/11 NOLAN, AMY 20110702 25.20 HMR/055 2011/07/11 NOLAN, AMY 20110702 112.77 HMK/oss 2011/07/11 NOLAN, AMY 20110702 47.88 HMK/055 2011/07/11 NOLAN, AMY 20110702 45.36 HMK/055 2011/07/11 HMR/055 2011/07/11 NOLAN, AMY 20110702 43.47 NOLAN, AMY 20110702 172.62 } K/oss toll/07/11 Report TD: PUR9080R PEBTF Claims Utilization Page: 3 P00043-001 Report Period 6/14/11 9/20/11 Run Date: 9/07/12 8:14:28 Selected By Cindicates Subscriber ** Discount Applied Name DOS Diag Cd, Procedure Net Amount Provider Claim # File/Plan Group Inv. Date NOLAN, AMY 20110702 64.26 HMK/055 2011/07/11 NOLAN, ANY 20110702 76.23 HMR/055 2011/07/11 NOLAN, AMY 20110702 418.32 HMR/055 2011/07/11 NOLAN, ANY 20110702 24.57 HMR/055 2011/07/11 NOLAN, AMY 20110702 65.52 HMK/055 2011/07/11 NOLAN, AMY 20110702 29.61 HMK/055 2011/07/11 NOLAN, AMY 20110702 325.08 HMK/055 2011/07/11 NOLAN, AMY 20110702 1,751.40 HMK/055 2011/07/11 NOLAN, AMY 20110702 3,294.67 HMK/055 2011/07/11 NOLAN, AMY 20110702 97$.87 HMK/055 2011/07/11 NOLAN, AMY 20110702 10.02 HMK/055 2011/07/11 NOLAN, AMY 20110702 3.28 HMK/055 2011/07/11 NOLAN, AMY 20110702 1.58 HMK/055 2011/07/11 NOLAN, AMY 20110702 98.31 HMK/055 2011/07/11 HMK/055 2011/07/11 NOLAN, AMY 20110702 122.85 HMK/055 2011/08/24 NOLAN, AMY 20110703 151:00 HMR/055 2011/08/24 NOLAN, AMY 20110705 151.00 NOLAN, AMY 20110707 151.00 HMK/055 2011/11/09 NOLAN, AMY 20110708 12.00 HMK/055 2011/07/11 HMK/055 2011/07/11 NOLAN, AMY 20110708 51.98 HMK/055 2011/07/11 NOLAN, AMY 20110708 139.23 HMK/055 2011/07/11 NOLAN, AMY 20110708 18.08 NOLAN, AMY 20110708 12.60 HMK/055 2011/07/11 NOLAN, AMY 20110708 112.77 HMR/055 2011/07/11 NOLAN, AMY 20110708 47.88 HMR/055 2011/07/11 NOLAN, AMY 20110708 93.87 HMR/055 2011/07/11 NOLAN, AMY 20110708 148.05 HMK/055 2011/07/11 NOLAN, AMY 20110708 76.23 HMR/055 2011/07/11 NOS AMY 20110708 65.52 HMK/055 2011/07/11 NOLAN, AMY 20110708 325.08 HMR/055 2011/07/11 NOLAN, AMY 20110708 925.87 HMR/055 2011/07/11 NOLAN, AMY 20110708 5.01 HMR/055 2011/07/11 HMR/055 2011/07/11 NOLAN, AMY 20110708 3.28 HMK/055 2011/07/11 NOS, AMY 20110708 122.85 NOLAN, AMY 20110708 200.00 HMK/055 2011/07/11 NOLAN, AMY 20110709 15.00 HMK/055 2011/07/11 NOLAN, AMY 20110710 86.12 HMK/055 2011/07/11 NOLAN, AMY 20110710 46.43 HMR/055 2011/08/03 NOLAN, AMY 20110710 25.92 HMR/055 2011/08/03 HMR/055 2011/08/03 NOLAN, AMY 20110710 27.96 NOLAN, AMY 20110710 31.03 HMK/055 2011/08/03 NOLAN, AMY 20110710 41.24 HMK/055 2011/08/03 NOLAN, AMY 20110710 31.80 HMK/055 2011/08/03 NOLAN, AMY 20110710 64.59 HMK/055 2011/08/03 NOLAN, AMY 20110710 17.36 HMK/055 2011/08/03 HMR/055 2011/08/03 NOLAN, AMY 20110710 527.37 NOLAN, AMY 20110710 339.89 HMK/055 2011/08/03 NOLAN, AMY 20110710 255.47 HMR/055 2011/08/03 Report ID: PUR9080R PPsBTP Claims Utilization Page: 4 I P00043-001 Report Period 6/14/11 9/20/11 Run Date: 9/07/12 8:14:28 III Subscriber Selected BY ** Indicates Discount Applied j DOS Diag Cd. Procedure Net Amount Provider Claim # Pile/Plan Group Inv. Date Name .71 HMR/055 2011/08/03 105 NOLAN, AMY 20110710 52 86 HMK/055 2011/08/03 NOLAN, ANY 20110710 HMR/055 2011/08/03 NOLAN, AMY 20110710 4.73 HMK/055 2011/08/03 NOLAN, AMY 20110710 2.50 76 HMR/055 2011/08/03 1 NOLAN, AMY 20110710 HMK/055 2011/08/03 NOLAN, AMY 20110710 1.03 HMR/055 2011/08/03 20110710 200.00 HMK/055 2013./08/03 Nam, AMY MY 20110710 2500 HMK/055 2011/12/28 . NOLAN, AMY 20110712 8 31 HMK/055 2011/12/28 NOLAN, AMY 20110712 HMK/055 2011/12/28 NOLAN, AMY 20110712 29.37 HMK/055 2011/12/28 NOLAN, AMY 20110712 31.03 HMK/055 2011/12/28 NOLAN, AMY 20110712 43'22 HMK/055 2011/12/28 NOLAN, AMY 20110712 13.30 HMR/055 2011/12/28 NOLAN, AMY 20110712 38.78 HMR/055 2011/12/28 NOLAN, AMY 20110712 43.22 HMR/055 2011/12/28 NOLAN, AMY 20110712 .82 HMK/055 2011/12/28 36. NOLAN, AMY 20110712 01 HMK/055 2011/12/28 NOLAN, AMY 20110712 45.43 HMK/055 2011/11/09 NOLAN, AMY 20110713 151.00 HMK/055 2011/08/03 NOLAN, AMY 20110718 34.52 IJMK/055 2011/08/03 NOLAN, AMY 20110718 31.80 HMK/055 2011/08/03 NOLAN, AMY 20110718 35.21 HMK/055 2011/08/03 NOLAN, AMY 20110718 17.36 HMR/055 2011/09/07 NOLAN, AMY 20110718 151.00 HMR/055 2011/09/07 NOLAN, AMY 20110720 151.00 HMK/055 2011/09/07 NOLAN, AMY 20110726 151.00 HMK/055 2011/09/07 NOLAN, AMY 20110728 151.00 HMK/055 2011/09/21 NOLAN, AMY 20110802 151.01 HMR/055 2011/08/24 NOLAN, AMY' 20110808 60.00 HMR/055 2013./08/24 NOLAN, AMY 20110808 102.30 HMK/055 2011/08/24 NOLAN, AMY 20110808 OS HMK/OSS 2011/08/24 NOLAN, AMY 20110808 28.79 HMK/055 2011/08/24 NOLAN, AMY 20110808 5'70 HMK/055 2011/08/24 NOLAN, AMY 20110808 30.21 HMK/055 2011/08/24 NOLAN, AMY 20110808 13'68 HMK/055 2011/08/24 NOLAN, ANY 20110808 159.03 HMR/055 2011/08/24 NOLAN, AMY 20110808 231.99 HMK/055 2011/08/24 NOLAN, AMY 20110808 28'79 HMK/055 2011/08/24 NOLAN, AMY 20110808 40'19 HMK/055 2011/08/24 NOLAN, AMY 20110808 45.03 HMK/055 2011/08/24 NOLAN, AMY 20110808 29.07 HMK/055 2011/08/24 NOLAN, AMY 20110808 90.24 HMK/055 2011/08/24 NOLAN, AMY 20110808 77'00 HMK/055 2011/08/24 NOLAN, AMY 20110808 12'50 HMK/055 2013./09/21 NOLAN, AMY 20110808 54.85 HMK/055 2011/09/21 NOLAN, AMY 20110808 95.02 HMK/055 2011/11/02 NOLAN, AMY 20110808 I' Report ID: PUR9080R PEBTF Claims Utilization Page: 5 P00043-001 Report Period 6/14/11 9/20/11 Run Date: 9/07/12 8:14:28 Selected By CGOLDAIndic Subscriber �+ Indicates Discount Applied Name DOS Diag Cd. Procedure Net Amount Provider Claim # Pile/Plan Group Inv. Date NOLAN, AMY 8.79 HMR/055 2011/11/02 NOLAN, AMY MINN20110808 5.70 HMK/055 2011/11/02 NOLAN, AMY 20110808 30.21 HMR/055 2011/11/02 NOLAN, AMY 20110808 13.68 HMK/055 2011/11/02 HMR/055 2011/11/02 NOLAN, AMY 20110808 159.03 HMR/055 2011/11/02 NOLAN, AMY 20110808 231.99 NOLAN, AMY 20110808 28.79 HMR/055 2011/11/02 NOLAN, AMY 20110808 40.19 HMK/055 2011/11/02 HMK/055 2011/11/02 NOLAN, AMY 20110808 45.03 NOLAN, AMY 20110808 29.07 HMK/055 2011/11/02 20110808 .08- HMK/055 2011/11/02 NOLAN, AMY NOLAN, AMY 20110808 28.79- HMK/055 2011/11/02 NOLAN, AMY 20110808 5.70- HMK/055 2011/11/02 NOLAN, AMY 20110808 30.21- HMK/055 2011/11/02 NOLAN, AMY 20110806 13.68- HMK/055 2011/11/02 NOLAN, AMY 20110808 159.03- HMK/055 2011/11/02 NOLAN, AMY 20110808 231.99- HMK/055 2011/11/02 NOLAN, AMY 20110808 28.79- HMK/055 2011/11/02 NOLAN, AMY 20110808 40.19- HMK/055 2011/11/02 NOLAN, AMY 20110608 45.03- HMK/055 2011/11/02 NOLAN, AMY 20110808 29.07- HMK/055 2011/11/02 NOLAN, ANY 20110808 54.85- HMK/055 2012/01/11 HMR/055 2012/01/11 NOLAN, AMY 20110808 95.02- HMK/055 2012/01/11 NOLAN, AMY 20110808 54.85 HMK/055 2012/01/11 NOLAN, AMY 20110808 95.02 NOLAN, AMY 20110809 151.00 HMK/055 2011/09/21 NOLAN, AMY 20110810 211.34 HMK/055 2011/08/24 NOLAN, AMY 20110810 138.00 HMK/055 2011/08/31 NOLAN, AMY 20110810 25.00 HMK/055 2011/08/31 NOLAN, AMY 20110811 17.05 HMK/055 2011/08/24 NOLAN, AMY 20110811 46.43 HMR/055 2011/08/24 NOLAN, AMY 20110811 31.03 HMR/055 2011/08/24 NOLAN, AMY 20110811 31.80 HMK/055 2011/08/24 NOLAN, AMY 20110812 200.00 HMK/055 2011/08/31 NOLAN, AMY 20110812 4.60 HMK/055 2011/08/31 NOLAN, AMY 20110812 51.98 HMR/055 2011/06/31 NOLAN, AMY 20110812 355.32 HMR/055 2011/08/31 NOLAN, AMY 20110812 49.14 HMK/055 2011/08/31 NOLAN, AMY 20110812 38.05 HMK/055 2011/08/31 NOLAN, AMY 20110812 12.60 HMK/055 2011/08/31 NOLAN, AMY 20110812 112.77 H4R/055 2011/08/31 NOLAN, AMY 20110812 47.88 HMK/055 2011/08/31 NOLAN, AMY 20110812 93.87 HMR/055 2011/08/31 NOLAN, AMY 20110812 148.05 HMK/055 2011/08/31 NOLAN, AMY 20110812 49.14 HMK/055 2011/08/31 NOLAN, AMY 20110812 76.23 HMK/055 2011/08/31 NOLAN, AMY 20110812 65.52 HMK/055 2011/08/31 NOLAN, AMY 20110812 3,294.67 HMR/055 2011/08/31 Report ID: PaR9080R PEBTF Claims Utilization Page. 6 P00043-001 Report Period 6/14/11 9/20/11 Run Date: 9/07/12 8:14:28 Selected By CGOLDA Subscriber ** Indicates Discount Applied Name DOS Diag Cd. Procedure Net Amount Provider Claim # File/Plan Group Inv. Date NOLAN, AMY 20110812 119.70 HMK/055 2011/08/31 NOLAN, AMY 20110812 975.87 HMK/055 2011/08/31 HMK/O55 2011/08/31 NOLAN, AMY 20110812 12.98, HMR/055 2011/08/31 1 NOLAN, AMY 20110812 20.03 HMK/055 2011/08/31 NOLAN, AMY 20110812 4.25 13.10 2011/08/31 NOLAN, AMY 20110812 13.10 HMK/055 2011/08/31 NOLAN, AMY 20110812 86.12 HMK/055 2011/08/31 NOLAN, AMY 20110813 130.00 HMK/055 2011/08/31 NOLAN, AMY 20110813 138.00 HMK/055 2011/09/14 NOLAN, AMY 20110813 6,644.06 HMK/055 2011/08/31 NOLAN, ANY 20110814 4.25 HMK/055 2011/08/31 NOLAN, AMY 20110814 3.28 HMK/055 2011/08/31 NOLAN, AMY 20110814 9.58 HMR/055 2011/08/31 NOLAN, AMY 20110814 541.00 HMK/055 2011/08/31 NOLAN, AMY 20110814 256.50 HMK/055 2011/10/12 NOLAN, AMY 20110814 256.50 HMK/055 2011/08/31 NOLAN, AMY 20110815 45.00 HMK/055 2011/08/31 NOLAN, AMY 20110816 75.00 HMK/055 2011/09/14 NOLAN, AMY 20110818 43.22 HMK/055 2011/09/14 NOLAN, AMY 20110818 102.30 Total Amount 48,580.71 PEBTF Claims Utilization Page: Report ID: , PUR9080R 1 Run Date: 9/07/12 8:14:09 P00043-001 Report Period 5/11/11 5/22/11 Subscriber Selected By CGO LDA ** indicates Discount Applied Provider Claim # File/Plan Group Inv. Date Name DOS Diag Cd. Procedure Net Amount HMK/055 2011/12/28 NOLAN, ANY 20110517 3.22 HMK/055 2011/12/28 NOLAN, AMY 20110520 52.26 HMR/055 2011/06/01 NOLAN, AMY 20110516 130.00 HMK/055 2011/06/01 NOLAN, AMY 20110516 130.00 HMK/055 2011/06/01 NOLAN, AMY 20110517 51.98 HMK/055 2011/06/01 NOLAN, AMY 20110517 131.67 HMK/055 2011/06/01 NOLAN, AMY 20110517 18.08 HMK/055 2011/06/01 6 NOLAN, AMY 20110517 45.3HMK/055 2011/06/01 NOLAN, AMY 20110517 3,105.67 HMK/055 2011/06/01 NOLAN, AMY 20110517 921.06 HMK/055 2011/06/01 NOLAN, ANY 20110517 10.02 HMK/055 2011/06/01 NOLAN, AMY 20110517 6.55 HMK/055 2011/06/08 NOLAN, AMY 20110517 83.85 HMK/055 2011/06/15 NOLAN, AMY 20110517 190.00 HMK/055 2011/06/22 NOLAN, AMY 20110519 183.25 HMK/055 2011/07/06 NOLAN, AMY 20110519 102.30 HMK/055 2011/07/13 NOLAN, AMY 20110519 8.55 HMK/055 2011/07/13 NOLAN, AMY 20110519 16.25 HMK/055 2011/07/13 NOLAN, AMY 20110519 42.75 HMK/055 2011/07/13 NOS, ANY 20110519 13.11 HMK/055 2011/07/13 NOLAN, AMY 20110519 25.65 HMK/055 2011/07/13 NOLAN, AMY 20110519 4.28 HMK/055 2011/07/13 NOLAN, AMY 20110519 , 41.90 HMK/055 2011/07/13 NOLAN, A14Y 20110519 39.05 HMK/055 2011/06/08 NOLAN, AMY 20110520 138.74 HMK/055 2011/06/08 NOLAN, AMY 20110520 .26 HMK/055 2011/06/08 272.83 NOLAN, AMY 20110520 HMK055 201 1/06/08 NOLAN, AMY 20110520 1,526.19 HMK%055 2011/06/08 NOLAN, AMY 20110520 52.12 HMK/055 2011/06/15 NOLAN, AMY 20110520 63.00 Total Amount 7,409.95 Penns lvania Em t )Vee Benefit Trust Fund TIME: 9:57:48 PROGRAM:DATE: PUR5010 RX9/05/12 aims iza ion PAGE: 1 Member Number -® Member Name NABP Rx NBR Fill Date Group Person NDC QTY D/SupCO-Pay Bill Amount AMY NOLAN 2011/30/30 11 A$10.00 01$2.92 TE u roup Number: � 2011/05/17 ACT? 01 AMY NOLAN 0 TA 20 10 $6.50 u roup Number: Argy NOLAN 2011/350/13 ACT? 01 01 5 TA Fu roup Number: NOLAN 2011/05/17 ACT? 01 UL 21 7 $10.00 $24.67 u roup Number: 2011/05/17 ACT? 01 NOLAN .50- 0 TA 20 10 $6 roup Number: NOT,AN 2011/05/17 ACT? 01 UL 21 7 $10.00- $24.67- u roup Number: ' NOLAN 2011/05/19 ACT? 01 5 TA 100 25 $10.00 $2.76 Fu 1 Group Number: 2011/05/19 ACT? 01 TM 120 30 $18.00 $222.58 �p NOLAN Number: NOLAN 2011/05/19 ACT? 01 TA 21 7 $10.00 $16.67 Fu Group Number: NOLAN 2011/30/ 23 A $10 .00 01$7.19 UL Full Group Number: Total Number of Rx Claims - 10 - Total Value of RX Claims From 2011/05/11 thru 2011/05/22 252.12 ** END OF REPORT Paget Report ID: PIIR9080R PEBTF Claims Utilization 1 P00043-001 Report Period 10/04/11 10/25/11 Run Date: 9/07/12 8:14:40 Selected By CGOLDA t� Discount lied Subscriber Indicates APP Name DOS Diag Cd. Procedure Net Amount Provider Claim # File/Plan Group Inv. Date NOLAN, AMY 20111007 64.00 IM/055 2011/10/19 NOLAN, AMY 34.00 HMK/055 2011/10/19 20111007 HMK/055 2011/10/19 NOLAN, AMY 20111007 5.96 HMK/055 2011/10/26 20111011 94.00 HMK/055 2011/10/26 NOLAN, ANY 34.00 NOLAN, AMY 20111011 5 75 HMK/055 2011/10/26 NOLAN, AMY 20111011 1 97 HMK/055 2011/10/26 NOLAN, AMY 20111011 HMK/055 2011/11/23 NOLAN, ANY 20111011 16.78 HMK/055 2011/11/23 NOLAN, AMY 20111011 11.91 HMR/055 2011/11/23 NOLAN, AMY 20111011 5.59 HMR/055 2011/11/23 NOLAN, AMY 20111011 3.50 HMK/055 2011/11/02 NOLAN, AMY 20111015 17.05 HMK/055 2011/11/02 NOLAN, AMY 20111015 29.99 HMK/055 2011/11/02 NOLAN, AMY 20111015 46.43 HMK/055 2011/11/02 NOLAN, AMY 20111015 20.66 HMR/055 2011/11/02 NOLAN, AMY 20111015 31.03 HMK/055 2011/11/02 NOLAN, AMY 20111015 289.89 HMR/055 2011/11/02 NOLAN, AMY 20111015 170.31 HMK/055 2011/11/02 NOLAN, AMY 20111015 158.57 HMR/055 2011/11/02 NOLAN, AMY 20111015 104.24 HMR/055 2011/11/02 NOLAN, AMY 20111015 52.86HMR/055 2011/11/02 NOLAN, AMY 20111015 13.108/055 2011/11/02 NOLAN, AMY 20111015 4 99 HMR/055 2011/11/02 NOLAN, AMY 20111015 2.83 HMK/055 2011/11/02 NOLAN, AMY 20111015 1.76 HMR/055 2011/11/23 NOLAN, ANY 20111015 200.00 HMx/055 2011/11/23 NOLAN, ANY 20111015 25.00 HMR/055 2011/11/02 NOLAN, AMY 20111016 1.03 HMK/055 2011/11/02 NOLAN, AMY 20111016 13.10 HMR/055 2011/11/02 NOLAN, AMY 20111016 4.99 HMR/055 2011/11/02 NOLAN, AMY 20111018 100.00 HMR/055 2011/I1/02 NOLAN, AMY 20111018 200.00 HMR/055 2011/11/09 NOLAN, AMY 20111018 6,213.28 HMR/055 2011/11/02 NOLAN, AMY 20111019 45.00 HMK/055 2011/11/09 NOLAN, AMY 20111019 56.00 HMR/055 2011/11/02 NOLAN, AMY 20111020 378'00 HMK/055 2011/11/09 NOLAN, AMY 20111020 399.00 HMK/055 2011/11/09 NOLAN, AMY 20111025 61.62 HMR/055 2011/11/16 NOLAN, AMY 20111025 48.48 Total Amount 8,966.67 PROGRAM: PUR5010 Pennsylvania Employee Benefit Trust Fund TIME: 9:57:57 DATE: 9/05/12 aims i iza ion PAGE: 1 Member Number - Member Name NABP Rx NBR Fill Date Group Person NDC Dru Descri tion QTY D/SupCo-Pay Bill Amount NOLAN 2011/20/ 10 A$10.00 01$2.76 TA u roup Number: NOLAN 2011/266 /13 A $3. 90 01 TA u roup Number: NOLAN 2011/000/16 30 ACT? 01 $18 TM .00 $102.94 u roup Number: NOLAN 2011/20/19 A 0 $10.00 $23.08 UL Full Group Number: NOLAN 2011/06/20 ACT? Ol TA 15 3 $3.02 u roup Number: NOLAN 2011/06/21 ACT? 01 I AMV TA 30 5 $6.05 u roup Number: NOLAN 2011/06/21 ACT? 01 TA 40 4 $5.88 Fu roup Number: NOLAN 2011/46/27 A $5.88 01 TA u ro p Number: NOLAN 2011/06/24 ACT? 01 TA 120 30 $10.00 $172.61 roup Number: NOLAN PR 2011/05/ 30 A $10.00 $124.87 Fu roup Number: NOLAN 2011/06/30 ACT? 01 TA 120 10 $10.00 $86.06 Fu Group Number: NOLAN 2011/07/08 ACT? 01 15 ¢ $3.05 u roup Number: AM= NOLAN 2011/070/03 ACT?9. 60 01 TA Full Group Number: Penns lvania Em to ee Benefit Trust Fund TIME: 9:57:57 PROGRAM: PUR5010 ayma y yza yon PAGE: 2 DATE: 9/05/12 Member Number - ®01 NABP Rx NBR Fill Date Group PerBon Member Name QTY D/SupCo-Pay Bill Amount NDC —"' Y NOLAN 2011/05/ 10 AC$1 -75 01 Ful Group Number: Y NOLAN 2011/07/13 10.00 A$ 01 10 0 $6.99 Fu Group Number: NOLAN 2011/07/12 ACT? 01 60 30 $18.00 $562.99 roup Number: AMY NOLAN 2011/60/12 10 A0 $10.00 $27.17 —PUTT Group Number: AMY NOLAN 2011/30/ ACO1 30 $7.43 Full Group Number: NOLAN 2011/07/12 ACT? 01 120 15 $10.00 $23.94 u roup Number: NOLAN 2011/30/ 30 7/12 A$10.00 01$2.96 U roup Number: NOLAN 2011/60/25 A0 $10.00 $27.17 roup Number: NOLAN 2011/07/20 ACT? 01 180 30 $18.00 $1,722.76 u roup Number 2011/i4/27 .01 ACT? 01 AMY NOLAN roup Number: . NOLAN 2011/08/04 ACT? 01 120 15 $10.00 $23.94 Fu Group Number y NOLAN 2011120/05 20 A0 $10.00 $63.23 u roup Number: 2011/08/08 ACT? $4.00 01 NOLAN 3030 Full Group Number: Penns lvania Em to ee Benefit Trust Fund TIME: 9:57:57 PROGRAM: PUR5010 aims .1"a ion PAGE: 3 DATE: 9/05/12 Member Number - — 01 Member Name NABP Rx NBR Fill Date Group Person NDC TY D gRRC.2 Pay Bill Amount 01 Dru Descri tion � —j _ :I AMY NOLAN 2011/25/25 08 A$10.00 $113.42 U roup Number. 2011/08/12 ACT? 01 NOLAN 10 5 $6.49 Number: NOLAN 2011/08/12 ACT? 01 30 4 $5.00 Fu Group Number: Y NOLAN 2011/28 /16 A $10.00 0$15.25 roup Number: pMy NOLAN 2011/30/12 30 A01 $10.00 $2.17 roup Number: NOLAN 20111180/15 AC$3.57 01 roup Number. AMY NOLAN 2011/25/ 13 AC$6.80 01 Full Group Number: 2011180 30 ACT? 01 NOLAN 180 30 $18.00 $1,722.76 u roup Number: NOLAN 2011/08/25 ACT? Ol 120 20 $10.00 $63.23 Full Group Number: 2011/08/25 ACT?0 01 NOLAN 40 5 $10.00 $1.61 Full Group Number: NOLAN 2011/25 /25 A0 $10.00 $78.75 Full Group Number: 2011/08/31 ACT?001$ AMY NOLAN 120 15 $10.00 $22.62 roup Number: 2011/09/07 ACT? 01 O1 NOLAN 3030 Fu roup Number: Penns lvania Em to ee Benefit Trust Fund TIME: 9:57:57 PROGRAM: PUR5010 aims i iza ion PAGE: 4 DATE: 9/05/12 Member Number - 01 Member Name NAEP Rx NBR Fill Date Group Person NDC Drug Description QTY D/SuUCo-Pay Bill Amount T 2011/09/07 ACT? 01 NOLAN 30 30 $10.00 $2.13 Fu Group Number: NOLAN 2011120/13 20 A 0 $10.00 $63.23 Full Group Number: 2011/09/13 ACI'? 01 NOLAN 180 30 $18.00 $1,722.76 Fu roup Number NOLAN 2011120/14 30 A 0 $10.00 $22.62 Full Group Number: 2011/09/15 ACT? 01 NOLAN 21 7 $10.00 $15.25 Fu Group Number: Total Number of Rx Claims - 44 . Total Value of RX Claims From 2011/06/14 thru 2011/09/20 - $6,819.27 ** END OF REPORT ** Report ID: PIJR9080R PEBTF Claims utilization page: 1 P00043-003 Report Period 3/06/12 4/22/12 Run Date: 9/07/12 8:15:14 Selected By CGOLDA Subscriber indicates Discount Applied Name DOS Diag Cd. Procedure Net Amount Provider Claim # File/Plan Group Inv. Date 20120308 HMK/055 2012/03/21 NOLAN, AMY 200.00 HMK/055 2012/03/21 NOLAN, ANY 20120308 .04 HMR/055 2012/03/21 20120308 57.98 NOLAN, AMY HMK/055 2012/03/21 20120308 53.57 NOLAN, AMY HMK/055 2012/03/21 27.46 20120308 NOLAN, AMY 31,03 HMK/055 2012/03/21 NOLAN, AMY 20120308 17.36 HMK/055 2012/03/21 NOLAN, AMY 20120308 HMK/055 2012/03/21 NOLAN, AMY 20120308 1,116.54 HMK/055 2012/03/21 NOLAN, ANY 20120308 11.90 HMK/055 2012/03/21 NOLAN, AMY 20120308 42.32 HMK/055 2012/03/21 NOLAN, AMY 20120308 594.62 HMK/055 2012/03/21 NOLAN, ANY 20120308 9.98 HMK/055 2012/03/21 NOLAN, AMY 20120308 1.76 HMK/055 2012/03/21 NOLAN, AMY 20120308 255.47 HMK/055 2012/03/21 NOLAN, AMY 20120308 52.86 HMK/055 2012/03/21 NOLAN, AMY 20120308 52.86 HMK/055 2012/03/21 NOLAN, AMY 20120308 52.12 HMK/055 2012/07/25 NOLAN, AMY 20120308 66.12 HMK/055 2012/04/04 NOLAN, AMY 20120321 57.98 HMK/05$ 2012/04/04 NOLAN, AMY 20120321 59.94 HMK/055 2012/04/04 NOLAN, AMY 20120321 27.46 HMK/055 2012/04/04 NOLAN, AMY 20120321 31.03 HMK/055 2012/04/04 NOLAN, AMY 20120321 544.62 HMK/055 2012/04/04 NOLAN, AMY 20120321 42.28 HMK/055 2012/04/04 NOLAN, AMY 055 2 120321 76.17.05 HMK/ 2012/04/04 0 NOLAN, AMY 20120321 2.83 HMK/055 2012/04/04 NOLAN AMY 20120321 158.57 HMK/055 2012/04/04 NOLAN, AMY 20120321 156.36 HMK/055 2012/04/04 NOLAN, AMY 20120321 HMK/055 2012/04/04 NOLAN, AMY 20120321 135.81 HMK/055 2012/04/04 NOLAN, AMY 20120321 85.16 HMK/055 2012/04/04 NOLAN, AMY 20120321 385.00 HMK/055 2012/04/04 NOLAN, AMY 20120321 89.31 HMK/055 2012/04/04 NOLAN, AMY 20120321 200.00 HMK/055 2012/04/11 NOLAN, AMY 20120323 138.00 HMK/055 2012/04/11 NOLAN, AMY 20120323 53.44 H4K/055 2012/04/11 NOLAN, AMY 20120323 57.98 HMK/055 2012/04/11 NOLAN, AMY 20120323 27.46 HMK/055 2012/04/11 NOLAN, AMY 20120323 31.03 HMK/055 2012/04/11 NOLAN, AMY 20120323 17.36 HMK/055 2012/04/11 NOLAN, AMY 20120323 346.41 HMK/055 2012/04/11 NOLAN, AMY 20120323 4.99 HMK/055 2012/04/11 NOLAN, AMY 20120323 2.50 HMK/055 2012/04/11 NOLAN, AMY 20120323 170.31 HMK/055 2012/04/11 NOLAN, AMY 20120323 52.86 HMK/055 2012/04/11 NOLAN, AMY 20120323 52.86 HMK/055 2012/04/04 M NOLAN, AY 20120326 45.00 HMK/055 2012/04/11 NOLAN, AMY 20120330 .00 i Report ID: PUR9080R PEBTF Claims Utilization Page: 2 i P00043-001 Report Period 3/06/12 4/22/12 Run Date: 9/07/12 8:15:14 Subscriber ® Selected By Indicates Discount Applied Name DOS Diag Cd. Procedure Net Amount Provider Claim # File/Plan Group Inv. Date NOLAN, AMY 20120330 .00 HMK/055 2012/04/11 NOLAN AMY 20120330 .00 HMK/055 2012/04/11 00 HMK/055 2012/04/11 NOLAN, AMY 20120330 HMK/055 2012/04/11 NOLAN, AMY 20120330 1,067.38 HMK/055 2012/04/11 NOLAN, AMY 20120330 264.24 HMK/055 2012/04/11 NOLAN, AMY 20120330 1,441.34 HMK/055 2012/04/11 NOLAN, AMY 20120330 87.84 HMK/055 2012/04/11 NOLAN, AMY 20120330 14.98 14MK/055 2012/04/11 NOLAN, AMY 20120330 14.09 HMK/055 2012/04/25 NOLAN, AMY 20120330 952.25 HMK/055 2012/04/25 NOLAN, AMY 20120330 15.50 HMK/055 2012/04/25 NOLAN, AMY 20120330 17.00 04K/055 2012/04/11 NOLAN, AMY 20120403 109.54 HMK/055 2012/04/11 NOLAN, AMY 20120403 93.00 HMK/055 2012/04/11 NOLAN, AMY 20120403 2.90 HMK/055 2012/04/18 NOLAN, AMY 20120409 45.00 MK/055 2012/04/18 NOLAN, AMY 20120409 7.71 HMK/055 2012/04/25 NOLAN, AMY 20120409 57.98 Total Amount 9,844.51 Pennsyl Em to ee Benefit Trust Fund TIME: 9:58:39 PROGRAM: PUR5010 aims i N ion PAGE: l DATE: 9/05/12 Member Number - MemNABP Rx NBR Fill Date Group Person Member Name Dru Descri tion QTY D/SupCo-Pay Bill Amount NDC AMY NOLAN 2012/03/ 01 AC$? Ol 1.72 Full Group Number: 2012/03/06 ACT? 01 NOLAN 3 1 $1.72- Full Group Number: 2012/03/10 ACT?0 01 AMY NOLAN � 200 17 $10.00 $36.70 u coup Number: AMY NOLAN 2012/03/16 ACT? 01 200 25 $10.00 $36.80 . p Number: 2012/03/16 ACT? 01 AMY NOLAN 21 5 $10.00 $24.48 roup Number: NOLAN 2012/30/ 30 3/25 A$10.00 01$2:17 u p Number: 2012/03/26 ACT? 01 yM NOLAN 10 30 $10.00 $258.24 roup Number: NOLAN 2012/03/27 ACT? 01 200 17 $10.00 $36.70 ur�up Number: NOLAN 2012/04/09 A CT? 01 20 20 $10.00 $525.38 Full Group Number 2012/04/09 ACT? 01 AMY NOLAN 200 33 $20.00 $139.19 Fu roup Number: Total Number of Rx Claims - 10 Total Value of R% Claims From 2012/03/06 thru 2012/04/22 - $1,059.66 ** END OF REPORT ** PROGRAMS PUR5010 Penns lvania Em to ee Benefit Trust Fund TIME: 9:58:29 DATE: 9/05/12 aims x iza xon PAGES 1 Member Number - Member Name NABP Rx NBR Fill Date Group Bi11Persont NDC Dru D escri tion QTY D/SupCo-Pay AMY NOLAN 2011/30/17 30 A 01 $10.00 $2.13 Numb er• AMy NOLAN 2011/11/18 ACT? 01 6 3 $4.33 u roup Number: AMJNOLAN 2011/20/13 AC$3.16 01 Full Group Number- AMY NOLAN 2011/21/16 A 0 $10.00 $15.25 u roup Number: AMY NOLAN 2011/11/19 ACT? 01 30 30 $7.78 u roup Number- 2011/11/19 2011/11/19 ACT? 01 30 30 $7.78- u roup Number: Total Number of Rx Claims - 6 Total Value of RX Claims From 2011/11/15 thru 2011/11/26 - $17.38 ** END OF REPORT ** SHERIFF'S OFFICE OF CUMBERLAND COUNTY ti ri Ron4iy-R Anderson Sheriff . r', U f t t�ararrLrrf'r�� Jody S Smith Chief Deputy Richard W Stewart Solicitor OFFICE cFTM=',=RIFF rr l e l ppiFf 19 l .L. �. e o l,�l�„ CL14:BERLAr. PENNS ;(:`, rl r, Pennsylvania Employee Benefit Trust Fund vs. Amy Nolan Case Number 2014-7203 SHERIFF'S RETURN OF SERVICE 12/16/2014 Ronny R Anderson, Sheriff, being duly sworn according to law, states he made diligent search and inquiry for the within named Defendant to wit: Amy Nolan, but was unable to locate the Defendant in his bailiwick. The Sheriff therefore returns the within requested Complaint & Notice as "Not Found" at 1105 E. Powderhorn Road, Hampden Township, Mechanicsburg, PA 17050. Deputies were advised by the current resident that they have lived at this address for 15 years and do not know the defendant, Deputies also attempted service at 1105W. Powderhorn Road and they residents at that address do not know the defendant either. SHERIFF COST: $44.79 SO ANSWERS, December 17, 2014 RONNY R ANDERSON, SHERIFF (c) CountySuite She , Telcosoft, L^c. SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny R Anderson Sheriff Jody S Smith Chief Deputy Richard W Stewart Solicitor OFF ‘`..E OF*E cEF^,IFF ,y x' 114 Pti �: { CUMBERLAND D! COU1'. PENNSYLV N1A Pennsylvania Employee Benefit Trust Fund vs. Amy Nolan Case Number 2014-7203 SHERIFF'S RETURN OF SERVICE 01/02/2015 07:55 PM - Deputy Shawn Gutshall, being duly sworn according to law, served the requested Complaint & Notice by handing a true copy to a person representing themselves to be Ian Jordan, Husband, who accepted as "Adult Person in Charge" for Amy Nolan at 8 Dulles Drive East, East Pennsboro Township, Camp Hill, PA 17011. twor UTS A , . UTY SHERIFF COST: $45.74 SO ANSWERS, January 05, 2015 RONIv? R ANDERSON, SHERIFF (c) CountySuite Sheriff, Te!eosoft, Inc.