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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applicableLines of Business (Check all NO ADDITIONAL PROVISIONS Medical Plan Services: Consumer Driven Health Plan: ® Participating Provider Option (PPO) ❑ BlueEdgeSM HCA Administrative Services (if ❑ Blue Choice Select PPO purchased complete separate HCA BPA) ❑ Blue Choice Options ® BlueEdgeSM HSA Eligible Health Plan(Preferred ❑ Blue High Performance NetworksM(BlueHPNSM) Vendor:Select Vendor)*If Health Equity, Inc. is selected, BCBSIL to send HSA enrollment to Additional Services: HealthEquity, Inc. ® Wellbeing Management ❑Yes ❑ No Non-Preferred Vendor: ❑ Wellness Incentives ❑ FSA(Preferred Vendor: Select Vendor)" ❑ Health Advocacy Solutions Non-Preferred Vendor: ❑ Mercer Health Advantage ❑ HRA(Preferred Vendor: Select Vendor)* ❑ Custom Care Management Unit Non-Preferred Vendor: ❑ Blue Directionssm(Private Exchange) (if selected, the Blue Directions Addendum is attached Prescription Drugs: and made a part of the parties'Administrative Services Agreement.) ® Covered under a pharmacy benefit(!f selected,the PBM Fee Schedule Addendum must be attached ❑Limited Fiduciary Services for Claims and and is part of this BPA.) Appeals ❑ Covered under the medical benefit or Blue Script ❑ Other Select Product Pharmacy Network(Select one): ❑ ® Traditional Select Network Other Select Product Advantage Network ❑ Other Select Product ❑ ❑ Preferred Network(Not offered with Blue Script) ❑ Other Select Product ❑ Elite Network(Not offered with Blue Script) ® Other Virtual Visits ❑ Network on PBM Fee Schedule Addendum ® Other Member Rewards ❑ Other(please specify): Ancillary Services: PPO Drug List: Balanced Drug List ❑ Dental Plan Services Other(please specify): ® Vision insurance (if selected, complete a separate application) PPO/HSA Preventive Drug List: ® Stop Loss (if selected, complete separate Please specify: Select Option Application and Policy Schedule for Stop Loss Coverage) Other Rx programs: ® Life, Disability, Critical Illness,Accident, or Please specify: Select Program Hospital Indemnity Insurance (if selected, complete a separate application for those Prescription Drug Program Clinical Programs coverages) ❑ Pharmaceutical Care Management(Retrospective) ® COBRA Administrative Services(if selected, (Included with HAS) complete separate HCSC COBRA Administrative Services Addendum) 'An HSA must be paired with a qualified high deductible health plan(HDHP)and follow strict requirements set forth by the Internal Revenue Service(IRS).Employer Groups should seek advice from their independent tax advisor,legal counsel,or other professional counselor,to ensure their proposed benefit strategy with respect to HSAs,FSAs, HRAs,or other benefit arrangements does not conflict with current IRS requirements. Mercer Health Advantage is offered by Mercer,an independent company,and is administered by Blue Cross and Blue Shield of Illinois. Custom Care Management Unit is offered by Willis"rowers Watson,an independent company,and is administered by Blue Cross and Blue Shield of Illinois. Medical and Dental benefits and services are administered by 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. Life,Disability,Critical Illness,Accident,Hospital Indemnity and Vision products are issued by Dearborn Life Insurance Company,701 E.22nd St.Suite 300,Lombard,1L 60148.Blue Cross and Blue Shield of Illinois is the trade name of Dearborn Life Insurance Company,an independent licensee of the Blue Cross and Blue Shield Association, BLUE CROW,BLUE SHIELD®and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association,an association of independent Blue Cross and Blue Shield Plans. 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 VBO 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 6