R2017-115 Agreement BlueCross BlueShield for Administration of City Group Health Benefit Plan for 2018

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® The last day of coverage is the last day of the month in which the limiting age is reached. ❑ The last day of coverage is the last day of the billing month. ❑ The last day of coverage is the last day of the year(12/31) in which the limiting age is reached. ❑ The last day of coverage is the day prior to the Employer's Anniversary Date. Will coverage for a child who is medically certified as disabled and dependent on the employee terminate upon reaching the limiting age even if the child continues to be both disabled and dependent on the employee? ❑ Yes ® No However, such coverage shall be extended in accordance with any applicable federal or state law. The Employer will notify HCSC of such requirements. 9. Will extension of benefits due to temporary layoff, disability or leave of absence apply? ❑Yes(specify number of days below) ® No Temporary Layoff: days Disability: days Leave of Absence: days However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with an applicable federal or state law. The Employer will notify HCSC of such requirements. 10. Enrollment: Special Enrollment: An Eligible Person may apply for coverage, Family coverage or add dependents within thirty-one (31) days of a Special Enrollment qualifying event if he/she did not previously apply prior to his/her Eligibility Date or when otherwise eligible to do so. Such person's Coverage Date, Family Coverage Date, and/or dependent's Coverage Date will be the effective date of the qualifying event or, in the event of Special Enrollment due to marriage or termination of previous coverage, then no later than the first day of the Plan Month following the date of receipt of the person's application of coverage. An Eligible Person may apply for coverage within sixty (60) days of a Special Enrollment qualifying event in the case either of a loss of coverage under Medicaid or a state Children's Health Insurance program, or eligibility for group coverage where the Eligible Person is deemed qualified for assistance under a state Medicaid or CHIP premium assistance program. Late Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when eligible to do so. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Open Enrollment. An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not apply prior to his/her Eligibility Date or did not apply when eligible to do so, during the Employer's Open Enrollment Period. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the Open Enrollment Period. Specify Open Enrollment Period: 12/1 to 12/31 11. * Does COBRA Auto Cancel apply? ❑Yes ® No Member's COBRA/Continuation of Coverage will be automatically cancelled at the end of the member's eligibility period. *Not recommended for accounts with automated eligibility. Lines of Business (Check all applicable services) NO CHANGES See Additional Comments Medical Plan Services: Consumer Driven Health Plan: ® Participating Provider Option (PPO) ❑ Health Care Account(HCA)Administrative ❑ Blue Choice Select PPO Services (if purchased, complete separate HCA BPA) ❑ Blue Choice Options ❑ BlueEdge FSA(Vendor: ConnectYourCare) Additional Services: ❑ HSA Eligible Health Plan(Vendor: ) ® Blue Care Connection® Prescription Drugs: Proprietary and Confidential Information of Claim Administrator Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except with written permission of Claim Administrator. HCSC IL GEN ASO BPA(Rev.08/17) A Division of Health Care Service Corporation,a Mutual Legal Reserve Company, 3 an Independent Licensee of the Blue Cross and Blue Shield Association