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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FLEXACCESSTm QUALIFIED HDHP: ❑Yes ® No Claim Administrator will assess a fee equal to 20%of program savings for administrative fees. Program savings (shared savings)will be calculated based on the manufacturer copay assistance dollars that are allocated to the cost of the drug minus the member's estimated cost share(copay or coinsurance)that would have been paid if they were not enrolled in the program. The difference between Employer Responsibility for claims utilizing FlexAccess Qualified HDHP and not utilizing FlexAccess Qualified HDHP includes as follows: WITH FLEXACCESS QUALIFIED HDHP: Cost of drug—amount manufacturer copay assistance used--Member out- of-pocket cost(if any)up to Deductible... Copay assistance reversed from deductible. Plan pays no portion. WITHOUT FLEXACCESS QUALIFIED HDHP:Cost of drug—member out-of-pocket cost-Non-FlexAccess Qualified HDHP coupon... Copay assistance applied to Deductible. Plan may pay portion of claim after deductible met Third-Party Law Firms Provisions(other than Reimbursement Services): Employer will pay no more than 35%of any recovered amount made by Claim Administrator's third-party law firm or up to 35%of any recovered amount will be deducted from the amount distributed according to established allocation processes. 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 Employer's payment for covered services under such Arrangements is described in the Administrative Services Agreement between the Claim Administrator and the Employer. Virtual Visits Program: ®Yes ❑ No if yes,Covered Persons would be able to obtain certain Covered Services remotely via interactive video and/or interactive audio/video(where available)capability from Virtual Visits powered by MDLIVE. MDLIVE'is a separate company that operates and administers Virtual Visits for persons with coverage through Blue Cross and Blue Shield of Illinois.MDLIVE is solely responsible for its operations and for those of its contracted providers.MDLIVE®and the MDLIVE logo are registered trademarks of MDLIVE,Inc-,and may not be used without permission, 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 Administrative Services 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 Administrative Services 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 Administrative Services 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 Administrative Services 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. 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 10