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

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Other Provisions NO CHANGES SEE ADDITIONAL PROVISIONS 1. Summary of Benefits&Coverage: a. Will Claim Administrator create Summary of Benefits& Coverage(SBC)? ® Yes. Please answer question b. The SBC Addendum is attached. ❑ No. If No, then skip question b and refer to the Administrative Services Agreement for further information. b. Will Claim Administrator distribute the Summary of Benefits&Coverage(SBC)to participants and beneficiaries? ® No. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the Agreement) and provide SBC to Employer in electronic format. Employer will then distribute SBC to participants and beneficiaries (or hire a third party to distribute) as required by law. ❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the Agreement) and provide SBC to Employer in electronic format. Employer will then distribute to participants and beneficiaries as required by law, except that Claim Administrator will send the SBC in response to the occasional request received directly from individuals. ❑ Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the Agreement) and distribute SBC to participants and beneficiaries via regular hardcopy mail or electronically. Distribution Fee for hardcopy mail is $1.50 per package. The distribution fee will not apply to SBCs that Claim Administrator sends in response to the occasional request received directly from individuals. 2. Massachusetts Health Care Reform Act: Does the Employer direct Claim Administrator to provide written statements of creditable coverage to its Covered Employees who reside, or have enrolled dependents who reside, in Massachusetts and file electronic reports to the Massachusetts Department of Revenue in a manner consistent with the requirements under the Massachusetts Health Care Reform Act? ®Yes ❑ No If no: The Employer acknowledges it will provide written statements and electronic reporting to the Massachusetts Department of Revenue as required by the Massachusetts Health Care Reform Act. 3. Case Management Program: ® Yes ❑ No The undersigned representative authorizes provision of alternative benefits for services rendered to Covered Persons for Utilization Management, Case Management, and other health care management programs. 4. Employer acknowledges and agrees to utilize Claim Administrator's standard list of services and supplies for which pre-notification or preauthorization is required: ® Yes ❑ No If no, Employer authorizes Claim Administrator to post Employer's pre-notification or preauthorization requirements on Claim Administrator's Website: ❑Yes ❑ No 5. Essential Health Benefits ("EHB") Election: Employer elects EHBs based on the following: ®1. EHBs based on a HCSC state benchmark: ® Illinois ❑ Oklahoma ❑ Montana ❑Texas ❑ New Mexico ❑2. EHBs based on benchmark of a state other than IL, MT, NM, OK and TX If so, indicate the state's benchmark that Employer elects: _ ❑3. Other EHB, as determined by Employer In the absence of an affirmative selection by Employer of its EHBs, then Employer is deemed to have elected the EHBs based on the Illinois benchmark plan. 6. This ASO BPA is binding on both parties and is incorporated into and made a part of the Administrative Services Agreement with both such documents to be referred to collectively as the"Agreement' unless specified otherwise. 7. Producer/Consultant Compensation 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, 7 an Independent Licensee of the Blue Cross and Blue Shield Association