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Biut ms WueShield of iilinot <br /> City Of Decatur <br /> A5 P-aecic^`c-:he,^,ergo <br /> ary' 2CiE•December 3".2•___ <br /> CONDITIONS AND CAVEATS <br /> The Ad rekstratrve charge includes a network access fee for employees residing in HCSC serutce yeas(IL•MT.OK NM.TX).Claire incurred Outside HCSC service <br /> areas through the BlueCaro program may be assessed a BlueCard access tee of no more than 311%of the discount applied.not to exceed S2.000 per claim.An estimate <br /> of this access fee is.ncluoed in our projected caim figures. <br /> This quote is contingent upon the account signing new contract documents un a timely manner.If not signed.then HCSC may•tttrdras),andior revise the quote. <br /> Pharmacy Rebate Credit includes estimate of rebates for all categories of drugs.including specialty drugs.based on our book of business. <br /> If the presemption drug program is not administered by Prime today but is awarded the adminissation of the prescription drug program,the me6cai Gam cost me be reduced due <br /> to the integration of the medical and prescnption drug program. <br /> We reserve tire right to reurse or withdraw our offer if.at any time during the projected coverage period: <br /> -The actual number of enrolled contraas(on total,by product or by benefit plan),the SingletFaenily mix.or the Medicare,Non-Medicare ma vanes by at.10%from our projections. <br /> -Thinformation <br /> eupon whiter our projections wore based{bene![levels.censusklernographics.commissions.etc.)becomes outdated or inaccurate <br /> ',.eltbemg Management(Health Management d Advocacy program)is included in the quoted administration fee. <br /> Commissions are excluded from the quoted rales/lees.Upon inquiry from employer groups,HCSC will provide mfornaran to the employer group regarding commissions and <br /> other compensation pad to the employers agent by HCSC in connection with the employers policy or contract with HCSC. <br /> If a third party pharmacy benefit manager is selected,additional charges mill apply <br /> This Stop Loss quote is firth through 100112025. <br /> Note:For quotes/renewals that are illustrative or otherwise not locked in, 'mll require/review updated claim data which is vtNm 150 days of the quoted effective date <br /> A revised and final slop toss quoterrenewai wit be issued at that tit,. <br /> Projected Net Paid Claims for non-HMO Medical coverages on these exhIbis include Estimated Value Based Care Payments and Savings. <br /> Value Based Care paymens apply to Stop Loss Coverage <br /> BCBSIL retains the ngm to recoup monetary credits provided.any remaining implementation costs.shared savings or PG incentive fees born the clan sponsor in the event of early terrnrnation <br /> of the proposed coverage or contract,either in its entirety or'nth respect to certain custom services or programs included in this offer. <br /> If a third party stop toss canner selected.a TbiraPaM Stop Loss Cartier fee'till apply <br /> Offer is contingent upon proposed':Wellbeing Management package design Any modifications to the proposed package <br /> vall impact the'Wellbeing Management tee and Adminisvabve Fee. <br /> Administration Fee assumes Monthly claim funding. <br /> This quote assumes Pnme Therapeutics(Pets)Performance Select Buosjesar drug list and Traditional Select network. <br /> T1vs stop loss quote assumes a bioslmlar drug list.HCSC reserves the night to adjust rates and factors should the biosimiar drug list be removed. <br /> Quote includes Advanced Payment Review(APR)program under APR program savings model.All claim savings realized through the APR program are passed through to the customer <br /> on the claim Invoice.and HCSC will charge back 25%of the claim savings on the monthly administrative invoice. <br /> Effective January 1.2025,for nein business and renewals issued under this policy.SCBSIL reserves the note to apply users and adjust rates for the gene therapy ingredient costs and any claims nsk. <br /> Subsequent renewals,if and when issued,wrtl be subject to no new lasers or rale adjustments to the extent that the gene therapy ingredient cost for one or more of the gene therapies listed below <br /> is covered under the('tan administered by BCBSIL and was included in Paid Claims under the Plan BCBSIL reserves the nght to continue to laser and adjust rates for those members that were <br /> lasered in the pnor policy pend. <br /> w Cane ane gluesoare k-a gre wrraxra Care Moneta d.reraom ('untie <br /> saga Rem.Gangs,an M nt.rOe r lawn.*r e.mu.Gess are Sc.guru a,a+mum <br /> cta.0 n she qts,.„.:.I. <br /> .,b;no vanew..a.,..e,ocs,o. .......M..a.r..,va...s....,.,-ee., e...m:ecu., <br />