R2024-342 Resolution Authorizing Agreement and Amendment with BlueCross BlueShield of Ilinois for Administration of the City Group Health Benefit Plan for Calendar Year 2025

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Other . . Program NO ADDITIONAL PROVISIONS NSA Fees In connection with the claims, items,and services that are subject to the No Surprises Act("NSA")and disputed by a Provider,Employer agrees to pay Claim Administrator the following fees: • Fifty dollars($50)for each claim that is the subject of informal negotiation with a Provider(this fee will be charged in the event the Provider, in its sole discretion, determines that it will not accept the initial payment amount); and • An additional seventy-five dollars($75)per claim for each independent dispute resolution process("IDR') where Claim Administrator represents Plan(this fee will be charged in the event the Provider, in its sole discretion, determines that it will initiate IDR after the informal negotiation period): and • All costs imposed by the IDR entity or any state,federal or focal government entity in connection with an IDR. External Review Coordination: ®Yes ❑ No !f 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 If no,provide name and address of administrator(s)of external review coordination and indicate if administrating medical claims and/or pharmacy claims: Administrator: Medical claims: ❑Pharmacy claims: ❑ Name: Mailing Address: Administrator: Medical claims: ❑Pharmacy claims: ❑ Name: Mailing Address: Advanced Payment Review(APR): El Yes ❑No APR is a suite of payment integrity offerings. Refer to the ABS. If Employer elects APR, indicate APR Savings Program or PEPM below: ® APR Savings Program ❑ PEPM For APR capabilities other than Reimbursement Services: If Employer elects APR Savings Program, Claim Administrator will invoice the percentage indicated in the Fee Schedule of any savings amounts identified by Claim Administrator or third-party vendor. Reimbursement Services: ®Yes ❑ No If yes, Claim Administrator will retain twenty-five percent(25%)of any recovered amounts made on third-party liability claims other than recovery amounts received as a result of or associated with any Workers'Compensation Law. FlexAccessTm: ❑Yes ® No As part of its plan design, Employer has directed Claim Administrator to administer claims, copay and coinsurance requirements for Covered Persons enrolled in the FlexAccess program, including (i)adjusting Covered Persons' copayment amounts to the amount of the manufacturer copay assistance, (ii)applying such manufacturer assistance to reduce Covered Persons'out of pocket costs, and (3)not applying the manufacturer assistance to Covered Persons' deductibles and out of pocket maximum accumulators. Employer agrees that FlexAccess is a plan design decision of Employer and is consistent with Employer's plan design and supported by plan documents. Employer further agrees it is solely responsible for, and will hold Claim Administrator harmless for,the legal and regulatory compliance of the Plan and its plan design. Claim Administrator will assess a program fee equal to 20%of the total shared savings. Total shared savings is calculated as follows: The difference between Employer responsibility without the FlexAccess Program and Employer responsibility with the FlexAccess Program.The Employer responsibility with the FlexAccess Program is the cost of the drug minus: (9)the manufacturer copay assistance dollars that are allocated to the cost of the drug and(2)the member's cost share for the member enrolled in the program.The Employer responsibility without the FlexAccess Program is the cost of the drug minus the member cost share if the member was not enrolled in the program. 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. IL GEN ASO VBD BPA(Rev.06.24)Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual Legal Reserve Company,an Independent licensee of the Blue Cross and Blue Shield Association 9