R2010-233 AUTHORIZING AGREEMENT - Laserfiche WebLink

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. ❑ Base Plus � Blue Care Connection`� FEE SCHEDULE - • ' - • • To begin on Effective Date of Coverage and continue for: � 12 Months ❑ Other(please specify): Months � • • % of Claim Payments or$55.15 per Covered Employee per month � Applies to all coverages ❑ Different percentage(s) or amount(s)for the following types of coverages. Please specify: Subscriber Share Methodology for Illinois Network Provider Claims Applies: � Yes ❑ No (If no,a letter declining Subscriber Share Methodology for Claims processing must be attached to this Benefit Program Application.) ' � • ' • � - � Group Number(s): P22346, P22347, P22348, P22349 � % of ADP Savings: 1.75% ❑ $ per Covered Employee per month: $ Comp/ete for Groups with mu/tip/e Provider Access Fees by products(i.e., CMM,PPO and/or POS plans): Group Number(s): ❑ % of ADP Savings: % ❑ $ per Covered Employee per month: $ BlueCard Program/Network access fees: Available upon request. • • • ' • • Prescription Drug Rebate: $12.82 per Covered Employee per month is the guaranteed Prescription Drug Rebate savings reflected as a Prescription Drug Rebate credit. Expected rebate amounts to be received by the Claim Administrator are passed back to the Employer with one hundred percent (100%) of the expected amount applied as a credit on the monthly billing statement on a per Covered Employee per month basis. Rebate credits are paid prospectively to the Employer and shall not continue after termination of the Prescription Drug Program. (Further information concerning this credit is included in the governing Administrative Services Agreement to which this ASO BPA is attached under the section titled "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PHARMACY BENEFIT MANAGERS." Not applicable to Grandfathered Plans External Review Coordination: If selected, Employer acknowledges and agrees: (i) to a fee of$700 for each external review requested by a Covered Person that the Claim Administrator coordinates for the Employer in relation to the Employer's Plan; (ii) that the Claim Administrator's coordination shall include reviewing external review requests to ensure that they meet eligibility requirements, referring requests to accredited external independent review organizations, and reversing the Plan's determinations if so indicated by external independent review organizations; and (iii)that the external reviews shall be performed by an independent third party entity or organization and not the Claim Administrator. Amounts received by Claim Administrator and external independent review organizations may be revised from time to time and may be paid each time an external review is undertaken. Further, Employer elects for external reviews to be performed under the process selected below(select one): ❑ State of Illinois External Review Process Federal Affordable Care Act Process HCSC IL GEN ASO BPA Rev. 9.1.10(On-line Version) page 4