R2015-120 AUTHORIZING CITY MANAGER TO SIGN AGREEMENT Bluecross Blueshield of Illinois

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BlueCard Program/Network access fees: Available upon request. Other Service and/or Program Fee(s) � NO CHANGES ❑ SEE ADDITIONAL PROVISIONS 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 Reimbursement Provision: � Yes ❑ No If yes: It is understood and agreed that in the event the Claim Administrator makes a recovery on a third-party liability claim,the Claim Administrator will retain 25°/a of any recovered amounts other than recovered amounts received as a result of or associated with an Workers' Com ensation Law. Conversion Privilege: ❑ Yes � No If yes, conversion fee: $6,000 per conversion. Claim Administrator's Third Party Recovery Vendor: It is understood and agreed that in the event the Claim Administrator's Third Party Recovery Vendor makes a recovery on a claim, the Em lo er will a no more than 25% of an recovered amount. Alternative Compensation Arrangements: Employer acknowledges and agrees that Claim Administrator has Alternative Compensation Arrangements with contracted Providers, including but not limited to Accountable Care Organizations and other Value Based Programs. Further information concerning Employer's payment for Covered Services under such Arrangements is described in the Administrative Services Agreement. Termination Administrative Charge As applies to the Run-Off Period indicated in the Payment Specifications section below: i. For service charges (including, but not limited to, access fees) billed on a per Covered Emp/oyee basis at the time of termination, the Termination Administrative Charge will be the amount equal to ten percent (10%) of the annualized charges based on the service charges in effect as of the termination date and the Plan participation of the finro (2) months immediately preceding the termination date. Such aggregate amount will be due the Claim Administrator within ten (10) days of the Claim Administrator's notification to the Employer of the Termination Administrative Charge described herein. ii. For service charges (including, but not limited to, access fees) billed on a basis other than per Covered Emp/oyee at the time of termination,the Termination Administrative Charge will be such service charges in effect at the time of termination to be applied and billed by the Claim Administrator, and paid by the Employer, in the same manner as prior to termination. Termination Administrative Charges assume the continuation of the Plan benefit program(s) and the administrative services in effect prior to termination. Should such Plan benefit program(s) and/or administrative services change, or in the event the average Plan enrollment during the three (3) months immediately preceding termination varies by ten percent (10%) or more from the enrollment used to determine the service charges in effect at the time of termination, the Claim Administrator reserves the right to adjust the rates for service charges (including, but not limited to, access fees) to be used to compute the Termination Administrative Charge. Broker/Consultant Compensation The Employer acknowledges that if any broker/consultant acts on its behalf for purposes of purchasing services in connection with the Employer's Plan under the Administrative Services Agreement to which this ASO BPA is attached, the Claim Administrator may pay the Employer's broker/consultant a commission and/or other compensation in connection with such services under the Agreement. If the Employer desires additional information HCSC IL GEN ASO BPA(Rev. 5.15) page 7