No insurance carriers on this filing. Self-funded welfare plans typically pay TPAs and PBMs through Schedule C, not Schedule A.
No brokers reported on this filing.
| Provider | Services | Address | Compensation |
|---|---|---|---|
| EXPRESS SCRIPTS PRESCRIPTION SERVICES | Other fees Service code 99 | 1 EXPRESS WAY ST. LOUIS, MO 63121 | $314K |
| SOUTHERN BENEFITS ADMINISTRATOR INC EIN 59-6154877 PLAN ADMINISTRATOR | Contract Administrator Service code 13 | PO BOX 1449 GOODLETTSVILLE, TN 37070 | $118K |
| CONNECTICUT GENERAL LIFE INS CO EIN 06-0303370 CLAIMS MANAGEMENT & PRICI | Claims processing Service code 12 | 5089 COLLECTION CENTER DR CHICAGO, IL 606930050 | $84K |
| MEDICAL EXCESS STOP LOSS INSURANCE | Insurance services Service code 23 | P.O. BOX 842173 LOS ANGELES, CA 900842173 | $77K |
| THE SEGAL COMPANY EIN 13-1975125 MEDICAL CLAIMS CONSULTANT | Consulting (general) Service code 16 | 101 NORTH WACKER DRIVE CHICAGO, IL 606061724 | $47K |
| GRAMLING & HAYA, CPA'S, PA EIN 59-1891796 AUDIT & TAX PREPARATION | Accounting (including auditing) Service code 10 | P.O. BOX 290069 TAMPA, FL 33687 | $17K |
| VENABLE LAW FIRM, PA EIN 59-1824867 LEGAL SERVICES | Legal Service code 29 | 7402 N 56TH ST,SUITE 380 TAMPA, FL 33617 | $13K |
| CIGNA BEHAVIORAL HEALTH CLAIMS CONSULTING | Consulting (general) Service code 16 | 11095 VIKING DR 800-433-5768 EDEN PRAIRIE, MN 55344 | $5K |
| SOUTHERN BENEFIT ADMINISTRATORS,INC EIN 59-6154877 PRINTING & POSTAGE | Contract Administrator Service code 13 | P.O. BOX 1449 GOODLETSVILLE, TN 370701449 | $4K |
Benefits declared on the Form 5500 main form (✓ = also has a Schedule A insurance contract; otherwise the benefit is funded out of plan assets or via a Schedule C TPA).
The plan reports several different headcounts depending on which form you read. Each one measures a different slice of the population.
| Active participants | 217 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 19 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 236 | Active + retired/separated + beneficiaries. No dependents. |
No Schedule A insurance contracts on this filing — typical of fully self-funded plans, where the only headcount is the Form 5500 number above.
Why the numbers differ. Form 5500 line 6 counts employees + retirees + beneficiaries; no dependents. Schedule A persons-covered counts everyone enrolled, including spouses and children, so it usually exceeds line 6 by 30-60% on a working-age workforce. The medical row is normally the broadest single line because it has the highest take-up; dental/vision/life often dip below it. Stop-loss / reinsurance contracts sometimes report the carrier's full underwriting pool rather than this filer's headcount; the row is shown for transparency but shouldn't be read as "people in this plan."
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.