R2016-136 BlueCross BlueShield Administration of Group Health Benefit Plan 2017

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24.37"Prescription Drug Program Eligible Charge" means (a) in the case of a Provider which has a written agreement with Claim Administrator, a Blue Cross and/or Blue Shield Plan or the entity chosen by Claim Administrator to administer its prescription drug program, to provide prescription drug services to a Covered Person at the time Covered Services under the prescription drug benefit are rendered ("Participating Prescription Drug Provider"), the lesser of such Provider's Claim Charge or the cost agreed upon by the Participating Prescription Drug Provider; and (b) in the case of a Provider which does not have a written agreement with Claim Administrator, a Blue Cross and/or Blue Shield Plan or the entity chosen by Claim Administrator to provide prescription drug program,to provide prescription drug services to a Covered Person at the time Covered Services under the prescription drug benefit are rendered ("Non-Participating Prescription Drug Provider"), the lesser of the following charges for Covered Services: i. the charge which the particular Non-Participating Prescription Drug Provider usually charges for Covered Services, or ii. the amount Claim Administrator would reimburse Participating Prescription Drug Providers for the same service, minus 25% unless otherwise agreed upon by Claim Administrator and Employer. 24.38"Participating Healthcare Provider" means a healthcare Provider that has a contractual agreement with a Host Blue. 24.39 "Patient-Centered Medical Home" means a model of care in which each patient has an ongoing relationship with a Primary Care Physician who coordinates a team to take collective responsibility for patient care and, when appropriate, arranges for care with other qualified Physicians. 24.40"Physician" means a physician duly licensed to practice medicine in all of its branches. 24.41 "Plan" means, as applied to this Agreement, the separate self-insured group health plan as defined by Section 160.103 of HIPAA. 24.42"Primary Care Physician" means a Physician who is a Network Provider at the time Covered Services are rendered who is selected by or assigned to a Covered Person to coordinate and arrange for the Covered Person's medical care and who provides medical care within the scope of a license permitting him/her to legally practice medicine in the recognized areas of pediatrics, obstetrics and gynecology, internal medicine and family practice. 24.43"Private Duty Nursing Service" means J1000) Skilled Nursing Service provided on a one-to-one basis by an actively practicing registered nurse (R.N.) or licensed practical nurse (L.P.N.). Private Duty Nursing Service is shift nursing of eight (8) hours or greater per day and does not include nursing care of less than eight(8) hours per day. Private Duty Nursing Service does not include Custodial Care Service. 24.44"Provider" means any Hospital, health care facility, laboratory, person or entity duly licensed to render Covered Services to a Covered Person or any other provider of medical or dental services, products or supplies which are Covered Services. 24.45"Provider Incentive" means an additional amount of compensation paid to a healthcare Provider by a Blue Cross and/or Blue Shield Plan, based on the Provider's compliance with agreed-upon procedural and/or outcome measures for a particular population of Covered Persons. 24.46 "Services" means the services listed in Exhibit 1. 24.47 "Shared Savings" means a payment mechanism in which the Provider and the Blue Cross and/or Blue Shield Plan share cost savings achieved against a target cost budget based upon agreed upon terms and may include downside risk. 24.48"Skilled Nursing Service" means J1000, S9123, S9124) those services provided by a registered nurse (R.N.)or licensed practical nurse(L.P.N.)which require the clinical skill and professional training of an R.N. or L.P.N. and which cannot reasonably be taught to a person who does not have specialized skill and professional training. Benefits for Skilled Nursing Service will not be provided due to the lack of willing or available non-professional personnel. Skilled Nursing Service does not include Custodial Care Service. 24.49"Supplemental Charge" means a fee or charge payable to Claim Administrator by Employer in addition to the fees and charges set forth in the Fee Schedule. A Supplemental Charge may be applied for any customized reports,forms or other materials or for any additional services or supplies not documented in the applicable Fee Schedule. Such services and/or supplies and any applicable Supplemental Charge(s) are to be agreed upon by the parties in advance. HCSC IL Gen ASA Med Non ERISA REG Rev.8.16 20 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.