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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14CSC GEN ASO Traditional PBM Fee Addendum 6.19 PBM Fee Schedule Addendum to the Benefit Program Application Cityo#Decatur ; _� Sat^., 0�l02/2DIS27,/31JZ6?5 ra"' ,552, Guaranteed Traditional Aggregate Pricing Arrangement C' Traditional Select Network and Balanced Drug List Brand Generic 'AWP;ibeihus •AWP minus.2t 19.40% 83.40% :;:DISPENSING:FEE Brand Generic $0.75 $0.75 Brand Generic AWP minusAWParrinus< 23.65% 85.85% .is DISPENSING FEEL Brand Generic AWPmMus , ;AWPminus = 85.85% '.DISPENSINGFEE 5000 Pricing based on Employer's use of the Prime Specialty network AWP minus:22.15% ..;>DISf!ENSI'NG FEE _ - i'�:SOAO PEPM Rebate Credits to Employer. {$128.45) PBM Administration Fees PEPM: Additional Provisions: s Employer will be billed for retail brand and mail generic prescriptions,mail brand and mail generic prescriptions,ESN brand and ESN generic,and Specialty phamracy claims(excluding compound prescriptions) based on the lesser of(a)U&C or(b)PBM's adjudication rate schedules)that is/are intended to achieve,on an aggregate calendar-year basis,the AWP discounts and Dispensing Fees shown above for all of Claim Administ oto's group customers that have purchased the above specific pricing arrangement("Groups with the Pricing arrangement")and use the above Network(the"Emptowr's Contract Rates'). For purposes of setting Employer's Contract Rates and calculating whether the AWP discounts and Dispensing Fees have been achieved: a.Brand drugs are defined as all drugs that have a Medi-Span inultisource,code field equal to"M","W,or"0". b.Generic drugs are defined as all drugs awilabte in sufficient supply that have a Medi-Spar muttisource code field equal to Employer acknowledges and agrees that Employers Contract Rates may vary based on market influences.and as necessary to achieve the AW P discounts and Dispensing Fees shown above,on an aggregate calendar year basis,for Groups with the Pricing Arrangement that use the above Network.However,such variation for Brand products in each of the Retail,Mail,and ESN categories(on an aggregate annual basis)may only vary by+/-3%from the applicable AWP discount shown above. Employer will be billed the above Dispensing Fee(such Fee may be included in the amount billed to Employer)unless the Employer is billed based on the U&C price.If the Employer is billed based on the U&C price,then the Dispensing fee is included in such U&C price. Employer vrdl be billed for Compound Drug claims baud on the applicable discounted rate in the Network Contract. Employer will be billed for Foreign Claims based on an amount equal to the amount billed by the pharmacy. Employer will be billed for outof-network claims based on the pricing set forth in the Administrative Services Agreement andlor PBM Exhibit,as appikable. If the Awp discounts and Dispensing Fees shown above are not achieved for a particular calendar year,for Groups with the Pricing Arrangement that use the above Network,then Employer will be credited,no later than 120 Clays after the end of each calendar year during the Term,an amount calculated as follows: -First,the total aggregate shortfall dollar amount for the calendar year for Groups with the Pricing Arrangement that use the above Network will be calculated by comparing the actual performance of each of the above categories iRetail,Mall,ESN,and Specialty)with the corresponding AWP discounts and Dispensing Fees shown above for each category.The amount of any performance in any category that exceeds the above AWP discounts and Dispensing Fees will be used to offset arty and all shortfall(s)in any or all categories.The above aggregate shortfall,if any,is then divided by total claims for Groups with the Pricing arrangement that use the above Network,and did not terminate their Addendum prior to their annimsary date,for the calendaryear("Per Claim Amount").Then the Per Claim Amount will be multiplied by Employers total claims for that calendar year to calculate the reconciliation credit-However,if Employer terminates this Addendum prior to its anniversary date and the above Guaranteed Traditional Aggregate Pricing arrangement is not achieved,then Employer will not be eligible to receive such credit. -For purposes of determining if a shortfall exists,claims billed to Employer based on the U&C price Will be considered to have S0.00 Dispensing Fees -Compound Drug claims,Foreign Claims,reversed claims,long term care(LTC)home infusion pharmacy,veterans affairs pharmacy,tndian/trihallurban pham:cy,3x08,Medicare/Medicaid,member submitted,coordination of benefits(COSI,subrogation,paper,invalid,usual and customary(U&C)claims,Covid related claims,Direct Member Submitted,and out-of-network claims are excluded from the calwtaton of whether the AWP discounts and Dispensing Fees shown. -Non-specialty discount and dispensing fees also exclude specialty(as defined by the BOBS specialty drug pricing fuel. -If the AWP discounts and Dispensing Fees shown above are exceeded for Groups with the Pricing Arrangement that use the above Network,then Employer will not receive any credit and there will not be a Veer end settlement -Under the Guarameed Traditional Aggregate Pricing Am ligament any particular group customer's experience relative to the pricing guarantees will not determine its eligibility fora credit.Group customer's eligibility for a credit is determined based on the aggregate experience of all group customers that have purchased the pricing Arrangement and use the above Network.As such,an individual group customer may have experience that does not meet,or exceeds,the AWP discounts and Dispensing Fees shown above.In addition,when there isa reconciliation credit,it is allocated in a manner described above and not based on any particulargmup's experience(other than number of ctaims). 1 Proprietary and Confidmdal Infrxmati- Nat for ase or disclosure outside Claim Administrator,Emptoyer.their respective affiliated companies and third party repeesentadves,crtept with written permission Of Claim Administrator.