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BlueCross BlueShield <br /> of Illinois <br /> APPLICATION AND POLICY SCHEDULE FOR STOP LOSS COVERAGE <br /> Employer Group Name: City of Decatur <br /> Employer Group Address: #1 Gary K.Anderson Plaza <br /> City: Decatur State of Situs:IL Zip Code:62523 <br /> Account Number: 022346 <br /> Employer Group Number(s): P22346,PE4337,PJ1005,PJ1009 <br /> Original Effective Date of Stop Loss Policy 01/01/2022 <br /> Current Policy Effective Date: 01101/2025 <br /> Current Policy Period The specifications set forth in this Application are for the Policy Period commencing on 01/01/2025 and <br /> ending on 12/31/2025. <br /> The specifications below shall become effective on the first date of the Policy Period specified above and shall continue in <br /> full force and effect until the earliest of the following dates: (1)The last day of the Policy Period; (2) The date the Policy <br /> terminates; or(3)The date this Application is superseded in whole or in part by a later executed Application. <br /> A. Covered Employees: <br /> Number of Single Coverage Units: 196 <br /> Number of Family Coverage Units: 355 <br /> B. Individual Stop Loss Coverage: <br /> 1. New Coverage❑ Renewal of Existing Coverage ED <br /> 2. Stop Loss coverage during the Current Policy Period <br /> ❑ Choose an stem <br /> Coverage for Claims incurred from to and Claims paid from to <br /> For new coverage only, if a run-in contract as explained in the Stop Loss Policy(24112, 18/12,or 15112 coverage <br /> period) is purchased, claims paid by the Employer Group's prior claim administrator will be settled at the time of <br /> the annual stop loss settlement and must be reported by the Employer Group to the Company (Blue Cross and <br /> Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company) by the <br /> end of the Employer Group's Current Policy Period or stop loss coverage for these run-in claims will be forfeited. <br /> ® (Paid Renewal Only) Claim Administrators Claims: Claims incurred on or after the Original Effective Date of <br /> Policy and paid during the Policy Period. <br /> 3. Covered Expenses includes: <br /> ® Medical Claims: <br /> ® Claim Administrator's Provider Access Fees <br /> ® Prescription Drug Claims with: Prime(Preferred PBM) <br /> ❑ For Hospital Employer Groups only: Excludes %of Home Hospital Medical claims <br /> ❑ Other(for example Dental/Vision): <br /> IL SL-APP Rev.3.21 <br /> A Division of Health Care Service Corporation,a Mutual Legal Reserve Company <br /> an Independent Licensee of the Blue Cross and Blue Shield Association <br />