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

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Claim Administrator Provider Access Fee(s) NO CHANGES SEE ADDITIONAL PROVISIONS Group Number(s): P22346, P22347, P22348, P22349, PE4337 ® %of ADP Savings: 1.57% ❑$ per Covered Employee per month: $ ❑ Group with multiple Provider Access Fees by services(e.g., CMM, and/or PPO plans); Group Number(s): ❑ %of ADP Savings: % ❑ $ per Covered Employee per month: $ BlueCard Program/Network access fees: Available upon request. • . . NO CHANGES SEE ADDITIONAL PROVISIONS External Review Coordination: ®Yes ❑ No If yes, coordination fee: $700 for each external review requested by a Covered Person that the Claim Administrator coordinates for the Employer in relation to the Employer's Plan. Employer elects the following process: ❑ State of Illinois External Review Process ® Federal Affordable Care Act Process Reimbursement Service: ®Yes ❑ No If yes:The Employer has elected to utilize the reimbursement service offered by the Claim Administrator, the Corporate Reimbursement Subrogation department. It is understood and agreed that in the event the Claim Administrator makes a recovery on a third-party liability claim, the Claim Administrator will retain 25%of any recovered amounts other than recovered amounts received as a result of or associated with any Workers' Compensation Law. Claim Administrator's Third Party Recovery Vendors and Law Firms(other than Reimbursement Services): Employer will pay no more than 25%of any recovered amount made by Claim Administrator's Third Party Recovery Vendor. Employer will pay no more than 35%of any recovered amount made by Claim Administrator's third party law firm. Alternative Compensation Arrangements: Employer acknowledges and agrees that Claim Administrator has Alternative Compensation Arrangements with contracted Providers, including but not limited to Accountable Care Organizations and other Value Based Programs. Further information concerning Employees payment for covered services under such Arrangements is described in the Administrative Services Agreement. Virtual Visits Program: ❑Yes ® No If yes, Covered Persons would be able to obtain certain Covered Services remotely via video or audio only(where available)capability from Providers participating in the Virtual Visit program. Termination Administrative Charge As applies to the Run-Off Period indicated in the Payment Specifications section above: I. For service charges(including, but not limited to, access fees) billed on a per Covered Employee basis at the time of termination of the Agreement or partial termination of Covered Employees, the Termination Administrative Charge will be the amount equal to ten percent (10%) of the annualized charges based on the service charges in effect as of the termination date or date of partial termination and the Plan participation of the two (2) months immediately preceding the termination date or date of partial termination. Such aggregate amount will be due the Claim Administrator within ten (10)days of the Claim Administrator's notification to the Employer of the Termination Administrative Charge described herein. ii. For service charges (including, but not limited to, access fees) billed on a basis other than per Covered Employee at the time of termination of the Agreement or partial termination of Covered Employees, the Termination Administrative Charge will be such service charges in effect at the time of termination of the Agreement or partial termination of Covered Employees to be applied and billed by the Claim Administrator, and paid by the Employer, in the same manner as prior to termination of the Agreement or partial termination of Covered Employees. 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.08117) A Division of Health Care Service Corporation,a Mutual legal Reserve Company, 6 an Independent licensee of the Blue Cross and Blue Shield Association