HomeMy WebLinkAboutResolution - 2022-R0416 - Contract 16694 with BlueCross BlueShield of TexasResolution No. 2022-RO416
Item No. 6.9
October 11, 2022
RESOLUTION
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock is hereby authorized and directed to execute
for and on behalf of the City of Lubbock, the B1ueCross B1ueShield of Texas Administrative
Services Only Benefit Program Application (ASO BPA) (Exhibit "A"), an Application and
Policy Schedule for Stop Loss Coverage (Exhibit "B"), and related documents. Said Exhibits
are attached hereto and incorporated in this resolution as if fully set forth herein and shall be
included in the minutes of the City Council.
Passed by the City Council on October 11, 2022
TRAY P E, M
ATTEST:
Qsl� A---'
Reb ca Garza, City Sec et
APPROV D CONTENT:
Clifton Beck, Director of Human Resources
AS FQTORM:
City Attorney
ccdocs/RES.Contract-BCBSTX
September 27, 2022
Resolution No. 2022-RO416
Fn HIBR
Benefit Program Application ("ASO BPA")
Application to Administrative Services Only (ASO) Group Accounts
administered by Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation,
a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, hereinafter referred to as the "Claim
Administrator" or "BCBSTX"
Group Status: Renewing ASO Account
Employer Account Number (6-digits): 010097 Group Number(s): 106837, 219476
Section Number(s): All
Legal Employer Name: City of Lubbock
(Specify the Employer or the employee trust applying for coverage. Names of subsidiary or affiliated companies to be covered must
also be named below. AN EMPLOYEE BENEFIT PLAN MAY NOT BE NAMED)
ERISA Regulated Group Health Plan*: ❑ Yes ® No
Is your ERISA Plan Year* a period of 12 months beginning on the Effective Date of Coverage specified below? ❑Yes
If not, please specify your ERISA Plan Year*: Beginning Date _/ /_ End Date /_/_ (month/day/year)
ERISA Plan Administrator*:
Plan Administrator's Address:
If you maintain that ERISA is not applicable to your group health plan, give legal reason for exemption:
Select from drop down; if applicable, specify other:
Is your Non-ERISA Plan Year* a period of 12 months beginning on the Anniversary Date specified below? ®Yes
If not, please specify your Non-ERISA Plan Year*: Beginning Date _/ /_ End Date / /_ (month/day/year)
For more information regarding ERISA, contact your Legal Advisor.
*All as defined by ERISA and/or other applicable law/regulations
Effective Date of Coverage: (Month/day/Year) 01 / 01 / 2023
Anniversary Date: (Month/Day/Year) 01 / 01 / 2024
Retiree -Only Plan(s) Identification:
For more information regarding Retiree -only plans, contact your Legal Advisor.
Do you have one or more Retiree -only plan(s)? ❑ Yes ® No
If yes, please provide Benefit Agreement number, or group and section numbers of the Retiree -only plan(s):
Standard Industry Code (SIC): 9111
Address: 1314 Avenue K
City: Lubbock
Administrative Contact: Lou Moore
Email Address: Imoore(cDmvlubbock.us
❑ Mailing address is different from primary address
Mailing Address:
City:
Mailing Contact:
Email Address:
® Billing address is different from primary address
Billing Address: PO Box 2000
City: Lubbock
Employer Identification Number (EIN): 75-6000590
State: TX
Title: Benefits and Wellness Manager
Phone Number: 806-775-2317
State:
Title:
Phone Number:
State: TX
Proprietary and Confidential Information of Claim Administrator
ZIP: 79401-3830
Fax Number: 806-775-
3316
ZIP:
Fax Number:
ZIP: 79457
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except
with written permission of Claim Administrator.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 1
Billing Contact: Lou Moore Title: Benefits and Wellness
Manager
Email Address: Imoore(a)mvlubbock.us Phone Number: 806-775-2317 Fax Number: 806-775-
3316
Wholly Owned Subsidiaries to be covered:
Affiliated Companies to be covered: Employer Identification Number (EIN):
(Affiliated Companies must be required or permitted to be aggregated per IRS Guidelines., Employer hereby confirms that Employer,
Subsidiaries and Affiliates are treated as a single employer under Internal Revenue Code Section 414(b), or (c), or (m) or (o), or under
applicable law.)
Subsidiary / Affiliate Address:
City: State: ZIP:
Subsidiary / Affiliate Contact: Title:
Email Address: Phone Number: Fax Number:
Blue Access for EmployersSm ("BAEsA°") Contact: Lou Moore Title: Benefits and Wellness
Manager
(The BAE Contact is the Employee authorized by the Employer to access and maintain the Employer's account in BAE.)
Email Address: Imoore(a)mvlubbock.us Phone Number: 806-775-2317 Fax Number: 806-775-
3316
® The Employer or other company listed in this BPA is a is a public Entity or governmental agency/contractor
Effective: 01 /01 /2016
If applicable, the below -named producer(s) or agency(ies) is/are recognized as the Employer's Producer of Record (POR)
to act as a representative in negotiations with and to receive commissions from BCBSTX, or Claim Administrator's
corporate subsidiaries, as applicable, for procuring Claim Administrator's claims administration services for Employer's
employee benefit program(s). This statement rescinds any and all previous POR appointments for the Employer. The
POR is authorized to perform membership transactions on behalf of the Employer. This appointment will remain in effect
until withdrawn or superseded in writing by Employer.
Producer or Agency to whom commissions are to be paid*: Marsh & McLennan Agency
Texas Producer #: 042758000 NPN: 263237576
Address:
City: State: ZIP:
Phone: Fax: Email:
Is Producer/Agency appointed with BCBSTX in Texas? ® Yes ❑ No General Agent? ❑ Yes ❑ No
Affiliated with General Agent? ❑ Yes ❑ No
Is there a secondary Producer or Agency to whom commissions are to be paid? ❑ Yes ® No
If Yes**, Producer or Agency to whom commissions are to be paid*:
Texas Producer*
NPN:
Address:
City: State: ZIP:
Phone: Fax: Email:
Is Producer/Agency appointed with BCBSTX in Texas? ❑ Yes ❑ No General Agent? ❑ Yes ❑ No
Commissions:
❑ PCPM $ Does a Monthly Cap Apply ❑ Yes ❑ No $ (If cap is annual, divide by twelve)
❑ Flat $ Does a Monthly Cap Apply ❑ Yes ❑ No $ (If cap is annual, divide by twelve)
❑ Percentage of Stop Loss: %
ADDITIONAL COMMISSIONS:
Affiliated with General Agent? ❑ Yes ❑ No
If commission split**, designate percentage for each producer/agency (total commissions paid must equal 100%):
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 2
Producer /Agency 1: % Producer /Agency 2: %
Multiple Location Agency(ies): If servicing agency is not listed above as primary or secondary Producer or Agency
above, specify location below:
* The Producer or agency name(s) above to whom commissions are to be paid must exactly match the name(s) on the appointment
application(s).
** If commissions are split, please provide the information requested above on both producers/agencies. Both must be appointed to
do business with BCBSTX in Texas.
Employer has made the following eligibility decisions:
1. Eligible Person means:
® A full-time employee of the Employer.
❑ A full-time employee of the Employer who is a member of. (name of union)
❑ A part-time employee of the Employer.
® A retiree of the Employer. Define criteria: Eligible to retire pre-65, or approved for disability retirement, under the
City of Lubbock retirement plans and has been employed by the City for five (5) consecutive years and enrolled
in the medical plan immediately preceding the date of retirement.
❑ Other:
Are any classes of employees to be excluded from coverage? ® Yes ❑ No
If yes, please identify the classes and describe the exclusion: Post-65 retirees on the group plan
2. Employee definition:
Full -Time Employee means:
® A person who is regularly scheduled to work a minimum of 30 hours per week and who is on the permanent
payroll of the Employer.
❑ Other:
Part -Time Employee means:
❑ A person who is regularly scheduled to work a minimum of hours per week and who is on the permanent
payroll of the Employer.
❑ Other:
3. The Effective Date of termination for a person who ceases to meet the definition of Eligible Person:
❑ The date such person ceases to meet the definition of Eligible Person.
® The last day of the calendar month in which such person ceases to meet the definition of an Eligible Person.
❑ Other:
4. Select an effective date rule for a person who becomes an Eligible Person after the Effective Date of the Employer's
health care plan (the effective date must not be later than the 91st calendar day after the date that a newly eligible
person becomes eligible for coverage, unless otherwise permitted by applicable law).
❑ The date of employment.
❑ The day of employment.
❑ The day of the month following month(s) of employment.
® The 1st day of the month following 30 days of employment.
❑ The day of the month following the date of employment.
❑ Other:
Is the waiting period requirement to be waived on initial group enrollment? ❑ Yes ❑ No
Are there multiple new hire waiting periods? ❑ Yes ❑ No
/fyes, please attach eligibility and contribution details for each section.
5. Domestic partners covered: ❑ Yes ® No
If yes, a domestic partner is eligible to enroll for coverage.
• yes, are domestic partners eligible for continuation of coverage? ❑ Yes ❑ No
/fyes, are dependents of domestic partners eligible to enroll for coverage? ❑ Yes ❑ No
If yes, are dependents of domestic partners eligible for continuation of coverage? ❑ Yes ❑ No
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 3
The Employer is responsible for providing notice of possible tax implications to those Covered Employees with
coverage for domestic partners.
6. Are unmarried grandchildren eligible for coverage? ®Yes ❑ No (answer the question below)
Must the grandchild be dependent on the employee for federal income tax purposes at the time application is
made? [:]Yes ❑ No
7. Limiting Age for covered children: Twenty-six (26) years, regardless of presence or absence of a child's financial
dependency, residency, student status, employment status, marital status, eligibility for other coverage, or any
combination of those factors. Other:
8. Termination of coverage upon reaching the Limiting Age:
❑ The last day of coverage is the day prior to the birthday.
❑ The last day of coverage is the last day of the month in which the limiting age is reached.
® The last day of coverage is the last day of the billing month.
❑ The last day of coverage is the last day of the year (12/31) in which the limiting age is reached.
❑ The last day of coverage is the day prior to the Employer's Anniversary Date.
Automatically cancel dependents when they reach the day their coverage terminates? ® Yes ❑ No
Will coverage for a child who is medically certified as disabled and dependent on the employee terminate upon
reaching the Limiting Age even if the child continues to be both disabled and dependent on the employee?
❑ Yes ® No
However, such coverage shall be extended in accordance with any applicable federal or state law and the Disabled
Dependent provisions of this BPA. The Employer will notify BCBSTX of such requirements.
9. Disabled dependent: A disabled dependent means a dependent child who is medically certified as disabled and
dependent upon the Employee or his/her spouse.
To administer medical certification of disabled dependents, you may select option (a) Standard Rules or (b) Custom
Rules. BCBSTX will administer its standard process for administration of disabled dependent coverage if (a) below is
selected by Employer, or at the Employer's direction memorialized below, BCBSTX will follow a customized process
if Employer selects (b). If (b) is selected there are additional selections regarding age, proof of prior coverage,
certification review, forms, and previous medical certification approvals.
(a) ® Disabled dependent administration will follow Standard Rules.
A disabled dependent is eligible to continue coverage beyond the limiting age, provided the disability began
before the child attained the age of 26. A disabled dependent is eligible to add coverage beyond the limiting age,
provided the disability began before the child attained the age of 26, and proof of coverage as a disabled
dependent is provided. Administration of certification review is administered by BCBSTX; a disabled dependent
certification form must be submitted to BCBSTX.
(b) ❑ Disabled dependent Administration will follow Custom Rules. Please make the following sections:
Age: Please select one option regarding age of when the disability began.
❑ The disability must have begun before the child attained the age of 26.
❑ All disabled dependents are covered regardless of when the disability began.
Proof of prior coverage: Please select required or not required below.
When adding coverage, proof of prior coverage as a disabled dependent is ❑ required ❑ not required.
Certification review: Please select one option regarding the administration of certification review.
❑ Certification review is administered by BCBSTX; a disabled dependent certification form must be submitted to
BCBSTX.
❑ Certification review is administered by the Employer; there are no disabled dependent certification form
requirements.
If certification review is administered by BCBSTX, please select one option regarding forms:
❑ Utilize BCBSTX's disabled dependent certification forms.
❑ Utilize custom/other disabled dependent certification forms.
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 4
If Certification Review is administered by BCBSTX, please select allowed or not allowed below.
A disabled dependent approved certification from a prior insurance carrier is ❑ allowed ❑ not allowed.
A disabled dependent approved certification from a prior BCBS policy is ❑ allowed ❑ not allowed.
10. Will extension of benefits due to temporary layoff, disability or leave of absence apply?
❑ Yes (specify number of days below) ❑ No
Temporary Layoff: days Disability: days Leave of Absence: days
However, benefits shall be extended for the duration of an Eligible Person's leave in accordance with any applicable
federal or state law. The Employer will notify BCBSTX of such requirements.
11. Enrollment:
Special Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents within thirty-one
(31) days of a Special Enrollment qualifying event if he/she did not previously apply prior to his/her Eligibility Date or
when otherwise eligible to do so. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage
Date will be the effective date of the qualifying event or, in the event of Special Enrollment due to marriage or
termination of previous coverage, then no later than the first day of the Plan Month following the date of receipt of the
person's application of coverage.
An Eligible Person may apply for coverage within sixty (60) days of a Special Enrollment qualifying event in the case
either of a loss of coverage under Medicaid or a state Children's Health Insurance program, or eligibility for group
coverage where the Eligible Person is deemed qualified for group coverage assistance under a state Medicaid or
CHIP premium assistance program.
Open Enrollment An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so, during the Employer's annual
Open Enrollment Period. Such person's Coverage Date, family Coverage Date, and/or dependent's Coverage Date
will be a date mutually agreed to by the Claim Administrator and the Employer. Such date shall be subsequent to the
Open Enrollment Period. Specify Open Enrollment Period:
Late Enrollment: An Eligible Person may apply for coverage, family coverage or add dependents if he/she did not
apply prior to his/her Eligibility Date or did not apply when otherwise eligible to do so. Such person's Coverage Date,
family Coverage Date, and/or dependent's Coverage Date will be a date mutually agreed to by the Claim
Administrator and the Employer.
Select one of the provisions below:
® Open Enrollment — Late applicants may only apply during Open Enrollment.
❑ Late Entrant — Late applicants may apply at any time — coverage effective date is determined by the receipt
date and allowed rules governing off -cycle enrollments.
12. * Does COBRA Auto Cancel apply? ® Yes ❑No
Member's COBRA/Continuation of coverage will be automatically cancelled at the end of the member's eligibility
period.
*Not recommended for accounts with automated eligibility
INFi CURRENT ELIGIBILITY ORMATION
® NO CHANGES ® Current number of Employees enrolled 2,501 ❑ SEE ADDITIONAL PROVISIONS
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 5
Current Employee Eligibility Information only applies to new accounts. If your account is renewing, please just indicate
the current number of enrolled employees (above).
Total number of Employees/Subscribers:
1. on payroll
2. total number of employees presently eligible for coverage
3. on COBRA continuation coverage
4. with retiree coverage (if applicable)
5. who work part-time
6. serving the new hire probationary period
7. declining because of other group coverage (e.g., other commercial group coverage, Medicare, Medicaid,
TRICARE/Champus)
8. declining coverage (not covered elsewhere)
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 6
Medical Plan Services: Consumer Driven Health Plan
❑ PPO: Plan Name: ❑ BlueEdgesM HCA, (if selected, complete separate HCA Benefit
Plan Name: Program Application)
Plan Name: ❑ BlueEdgesM HSA, (if selected, provide HSA Administrator or
trustee name: Select Vendorl
Plan Name:
❑ FSA (vendor: Select Vendor)
Plan Name:
❑ HRA (vendor: Select Vendor)
❑ HMO: Plan Name:
❑ Prescription Drug Option:
Select From List
❑ No Prescription Drug Option
❑ Blue High Performance NetworksM
(BlueHPNsM)
® EPO: Plan Name: EPO EPO
❑ POS: Plan Name:
Additional Services:
® Wellbeing Management
❑ Wellness Incentives
❑ Health Advocacy Solutions
❑ Mercer Health Advantage
❑ Custom Care Management Unit
❑ Blue DirectionssM (Private Exchange) (/f
selected, the Blue Directions Addendum must
be attached and made a part of the parties'
Administrative Services Agreement.)
❑ In -Hospital Indemnity (IHI)
Traditional Coverage:
❑ Out -of -Area (Indemnity)
❑ Benefit Offering
Prescription Drugs:
® (If selected, the PBM Fee Schedule Addendum must be attached
and is part of this BPA.)
Pharmacy Network (Select one):
❑ Traditional Select Network
® Advantage Network
❑ Preferred Network
❑ Elite Network
❑ Network on PBM Fee Schedule Addendum
❑ Other (please specify):
Drug List: Performance Drug List
Other (please specify):
PPO/HSA Preventive Drug List:
❑ Limited Fiduciary Services for Claims
Please specify: Select Option
and Appeals
Other Rx programs:
Please specify: Select Program
❑ Other Select Product
❑ Other Select Product
Ancillary Services:
❑ Vision Insurance (if selected, complete a separate application)
❑ Other Select Product
® Stop Loss Coverage (If selected, complete separate Stop Loss
❑ Other Select Product
exhibit)
❑ Other
❑ Life, Disability, Specified Disease or Accident Insurance (/f
selected, complete a separate application for those coverages)
❑ Other
® COBRA Administrative Services (If selected, complete separate
COBRA Administrative Services
® Dental Plan Services
Plan Name: PPO P Dental Employer -paid
Plan Name: Select From List
Plan Name: Select From List
Plan Name: Select From List
mv- neann r,avanrage m onerea oy mercer an inaepenaent company, and is administered by Blue Gross and Blue Shield of Texas
Custom Care Management Unit is offered by Willis Towers Watson, an independent company, and is administered by Blue Cross and Blue Shield of Texas
Medical and Dental benefits and services are administered by Blue Cross and Blue Shield of Texas. 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 Specified Disease Accident and Vision Insurance is underwritten by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300. Lombard, IL 60148. Blue Cross and Blue Shield of
Texas is the trade name of Dearborn Life Insurance Company an independent licensee of the Blue Cross and Blue Shield Association BLUE CROSS®. 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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 7
FEE SCHEDULE
Employer shall pay amounts Claim Administrator bills Employer for benefit claims Claim Administrator
processes on Employer's behalf as well as administrative fees as set forth in this Fee Schedule.
Payment Specifications NO CHANGES SEE ADDITIONAL PROVISIONS
Employer Payment Method: ❑ Online Bill Pay ❑ Electronic ❑ Auto Debit ❑ Check
Employer Payment Period: ❑ Weekly (cannot be selected if Check is selected as payment method above)
❑ Semi Monthly (cannot be selected if Check is selected as payment method above)
❑ Monthly
Claim Settlement Period: ❑ Monthly
Run -Off Period: Employer Payments are to be made for months following the end of the Fee Schedule Period.
Standard is twelve (12) months.
Fee Schedule Period: To begin on Effective Date of Coverage and continue for 12 months. If other than 12 months,
please specify: months.
Per Employee per Month
NO CHANGES
M SEE
ADDITIONAL PROVISIONS
ChargesAdministrative
2023 Medical
EPO
2023 Dental
2024
2025
Administrative Fee
$42.52
$3.20
$43.37
$4124
Dental
$
$
$
$
Limited Fiduciary Services
$
$
$
$
Advanced Payment Review
$
$
$
$
*Medical Drug Rebate Credit
$(2�
$(---1
$TBDI
$TBD
*Rebate Credit for the Prescription Drug Program
$ 9( 2.131
$(_�
$ Tf BDl
$TBD
Outpatient Imaging Management Services
$
$
$
$
Management of the Virtual Visits Program
$
$
$
$
Wellbeing Management
$4.95
$
$TBD
$TBD
Health Advocacy Solutions
$
$
$
$
Commissions:
$
$
$
$
Commissions:
$
$
$
$
Commissions:
$
$
$
$
Other: Prescription Drug Administrative Fee
$4.57
$
$TBD
$TBD
List Service:
Other: Other Services
$0.19
$
$TBD
$TBD
List Service: Retiree Drug Subsidy Supl)gort
Other: Select Service Category
List Service:
Miscellaneous:
$
$
$
$
Miscellaneous:
$
$
$
$
Total
$-42.40
$3.20
$TBD
$TBD
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 8
*The Rebate Credit is a per Covered Employee per month credit applied to the monthly billing statement. The Employer
and Claim Administrator have agreed to the Rebate Credit and Employer agrees that it and its group health plan have no
right to, or legal interest in, any portion of the rebates, either under the pharmacy benefit or the medical benefit, actually
provided by the Pharmacy Benefit Manager ("PBM") or a pharmaceutical manufacturer to Claim Administrator and
consents to Claim Administrator's retention of all such rebates. The Rebate Credit will be provided from Claim
Administrator's own assets and may or may not equal the entire amount of rebates actually provided to Claim
Administrator by the PBM or expected to be provided. Rebate Credits shall not continue after termination of the
Prescription Drug Program. Employer agrees that any Rebate Credit provision in the governing Administrative Services
Agreement to the contrary is hereby superseded.
Administrative Line Item ChargesFrequency
Other: Select Service Category
Select Billing Frequency
$
List Service:
If applicable, describe other:
Other: Select Service Category
Select Billing Frequency
$
List Service:
If applicable, describe other:
Other: Select Service Category
Select Billing Frequency
$
List Service:
If applicable, describe other:
Other: Select Service Category
Select Billing Frequency
$
List Service:
If applicable, describe other:
Miscellaneous:
Select Billing Frequency
$
If applicable, describe other:
Miscellaneous:
Select Billing Frequency
$
If applicable, describe other:
Miscellaneous:
Select Billing Frequency
%
If applicable, describe other:
Total:
$
NSA Fees
In connection with the claims, items, and services that are subject to the No Surprises Act ("NSA") and disputed by a
Provider, Employer agrees to pay Claim Administrator the following fees:
• Fifty dollars ($50) for each claim that is the subject of informal negotiation with a Provider (this fee will be charged
in the event the Provider, in its sole discretion, determines that it will not accept the initial payment amount); and
• An additional seventy-five dollars ($75) per claim for each independent dispute resolution process ("IDR") where
Claim Administrator represents Plan (this fee will be charged in the event the Provider, in its sole discretion,
determines that it will initiate IDR after the informal negotiation period); and
• All costs imposed by the IDR entity or any state, federal or local government entity in connection with an IDR.
Not applicable to Grandfathered Plans
External Review Coordination: ® Yes ❑ No
If yes, coordination fee: $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. Employer elects for external reviews to be performed
under the Affordable Care Act external review process.
/f no, provide name and address of administrator(s) of external review coordination and indicate if administrating medical
claims and/or pharmacy claims:
Administrator: Medical claims: ❑ Pharmacy claims: ❑ Name: Mailing Address:
Administrator: Medical claims: ❑ Pharmacy claims: ❑ Name: Mailing Address:
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.
TX GEN ASO SPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 9
Advanced Payment Review (APR): ® Yes ❑ No
APR is a suite of payment integrity offerings. Refer to the Matrix. If Employer elects APR, indicate APR Savings Program
or PEPM below:
® APR Savings Program
❑ PEPM
For APR capabilities other than Reimbursement Services: If Employer elects APR Savings Program, Claim
Administrator will invoice the percentage indicated in the Fee Schedule of any savings amounts identified by Claim
Administrator or third -party.
Reimbursement Services: ® Yes ❑ No If yes, Claim Administrator will retain twenty-five percent (25%) of any
recovered amounts made on third -party liability claims other than recovery amounts received as a result of or associated
with any Workers' Compensation Law.
FlexAccessTm: ❑ Yes ® No
Claim Administrator will assess a program fee equal to 20% of the total shared savings. Total shared savings is
calculated as follows:
The difference between Employer responsibility without the FlexAccess Program and Employer responsibility with the
FlexAccess Program. The Employer responsibility with the FlexAccess Program is cost of the drug minus: (1) the
manufacturer copay assistance dollars that are allocated to the cost of the drug and (2) the member's cost share for the
member enrolled in the program. The Employer responsibility without the FlexAccess Program is the cost of the drug
minus the member cost share if the member was not enrolled in the program.
Third -Party Law Firms Provisions (other than Reimbursement Services): Employer will pay no more than 35% of
any recovered amount made by Claim Administrator's third -party law firm or up to 35% of any recovered amount will be
deducted from the amount distributed according to established allocation processes.
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 between the Claim
Administrator and the Employer.
Virtual Visits Program: ❑ Yes ® No If yes, Covered Persons would be able to obtain certain Covered Services
remotely via interactive video and/or interactive audio/video (where available) capability from Virtual Visits powered by
MDLIVE.
wr..par �y "'I
uperarw anu aununrsrms vnmar v� slow rur perwns wim wverage mrougn mue uross ana time Anlelo Ot I exas Muuvt is soieiy responsioie for its operations and
for those of its contracted providers MDLIVE® and the MDLIVE logo are registered trademarks of MDLIVE Inc. and may not be used Nnthout permission
Termination Administrative Charges
As applies to the Run -Off Period indicated in the Payment Specifications section above:
The Termination Administrative Charge applicable to the Run -Off Period shall be equal to the sum of the amounts
obtained by multiplying the total number of Covered Employees by category (per Covered Employee per individual or
family composite) during the three (3) months immediately preceding the date of termination by the appropriate factors
shown below. In the event of a partial termination, the Termination Administrative Charge shall be the sum of the amount
obtained by multiplying three (3) times the total number of terminated Covered Employees by the appropriate factors
shown below.
Service
2023
Medical Run-off Administration Charge
$14.04
$
$
$
Dental Run-off Administration Charge
$
$
$
$
Miscellaneous
$
$
$
$
Miscellaneous
$
$
$
$
Total:
$14.04
1 $ 1
$
$
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 10
Other ProvisionsNo CHANGES SEE ADDITIONAL• •
1. Summary of Benefits & Coverage:
a. Will Claim Administrator create Summary of Benefits and Coverage (SBC)?
® Yes. (Please answer question b. The SBC Addendum is attached.)
❑ No. (If No, then skip question b and refer to the Administrative Services Agreement for further information.)
b. Will Claim Administrator distribute the (SBC) to Covered Persons?
❑ No. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Administrative Services Agreement) and provide SBC to Employer in electronic format. Employer will then
distribute SBC to Covered Persons (or hire a third party to distribute) as required by law.
® Yes. Claim Administrator will create SBC (only for benefits Claim Administrator administers under the
Administrative Services Agreement) and distribute SBC to plan participants and beneficiaries via regular
hardcopy mail or electronically. Distribution Fee for hardcopy mail is one dollar fifty cents ($1.50) per
package.
2. Massachusetts Health Care Reform Act:
Does the Employer direct Claim Administrator to provide written statements of creditable coverage to its Covered
Employees who reside, or have enrolled dependents who reside, in Massachusetts and file electronic reports to the
Massachusetts Department of Revenue in a manner consistent with the requirements under the Massachusetts
Health Care Reform Act? ® Yes ❑ No
If no: The Employer acknowledges it will provide written statements and electronic reporting to the Massachusetts
Department of Revenue if required by the Massachusetts Health Care Reform Act.
Alternative Care Management Program (applicable to the purchased medical management program):
❑ Yes ® No
The undersigned representative authorizes provision of alternative benefits for services rendered to Covered
Persons for Utilization Management, Case Management, including but not limited to Behavioral Health, and other
health care management programs.
4. Prior Authorization (applicable to the purchased medical management program): Employer acknowledges and
agrees to utilize Claim Administrator's standard list of services and supplies for which Prior Authorization (also called
pre -notification or preauthorization) is required.
5. Essential Health Benefits ("EHB") Election:
Employer elects EHBs based on the following:
1.0 EHBs based on a Claim Administrator state benchmark:
❑ Illinois ❑ Montana ❑ New Mexico ❑ Oklahoma ® Texas
2. ❑ EHBs based on benchmark of a state other than IL, MT, NM, OK and TX
If so, indicate the state's benchmark that Employer elects:
3. ❑ Other EHB, as determined by Employer
In the absence of an affirmative selection by Employer of its EHBs, then Employer is deemed to have elected the
EHBs based on the Texas benchmark plan.
6. Employer contribution:
Employer Contribution — Medical
Employer Contribution — Dental
% of Employee's premium, or $
% of Employee's premium, or $
% of Dependent's premium, or $
% of Dependent's premium, or $
Comments:
7. This ASO BPA is binding on both parties and is incorporated into and made a part of the Administrative Services
Agreement between the parties with both such documents to be referred to collectively as the "Administrative
Services Agreement" unless specified otherwise.
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas. a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 11
8. Producer/Consultant Compensation:
The Employer acknowledges that if any its POR 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 POR a commission and/or other compensation in connection with such
services under the Administrative Services Agreement. If the Employer desires additional information regarding
commissions and/or other compensation paid to the POR by the Claim Administrator in connection with services
under the Administrative Services Agreement, the Employer should contact its POR.
Additional Provisions: Wellness Allowance Credit of $25,000 will be provided annually.
BCBSTX will provide a one time $125 000 credit contingent upon the renewal of all lines of coverage beginning with the
Contract Period starting January 1. 2023.
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 on the claim invoice and HCSC will charge back 25% of
the claim savings on the monthly administrative invoice.
Upon Termination, the run-off administration fee will be multiplied times the total of all certificates actually exposed during
each of the three months immediately preceding contract termination and the result will be the obligation of the Employer.
The Run-off Administration amount is due and payable whether or not BCBSTX processes the run-off claims
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 12
Signature
Taylor Holbrook
Sales Representative 10/03/2022 Signature
034 972-766-2465
District Phone & FAX Numbers
Travis Sartain
Producer Representative
MarshMcClennan Agency
Producer Firm
8144 Walnut Hill Lane, 16th Floor
Dallas, TX, 75231
Producer Address
972-770-1438
Producer Phone & FAX Numbers
Travis.Sartain@MarshMMA.com
Producer Email Address
Tax I.D. No.
Tray Payne
Print Name
Mayor
Title
October 11, 2022
Date
Proprietary and Confidential Information of Claim Administrator
Purchaser
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except
with written permission of Claim Administrator.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 13
PROXY
The undersigned hereby appoints the Board of Directors of Health Care Service Corporation, a Mutual Legal Reserve
Company, or any successor thereof ("HCSC"), with full power of substitution, and such persons as the Board of Directors
may designate by resolution, as the undersigned's proxy to act on behalf of the undersigned at all meetings of members
of HCSC (and at all meetings of members of any successor of HCSC) and any adjournments thereof, with full power to
vote on behalf of the undersigned on all matters that may come before any such meeting and any adjournment thereof.
The annual meeting of members is scheduled to be held each year in the HCSC corporate headquarters on the last
Tuesday of October at 12:30 p.m. Special meetings of members may be called pursuant to notice provided to the member
not less than thirty (30) nor more than sixty (60) days prior to such meetings. This proxy shall remain in effect until either
revoked in writing by the undersigned at least twenty (20) days prior to any meeting of members or by attending and
voting in person at any annual or special meeting of members.
From time to time, HCSC pays indemnification or advances expenses to its directors, officers, employees or agents
consistent with HCSC's bylaws then in force and as otherwise required by applicable law.
Group No.: 010097 By: Tray Payne
ne
Group Name: City of Lubbock
Address: 1314 Avenue K
City: Lubbock
Dated this 11th day of
PriW/xj
e
Mayor
Si
State: TX ZIP: 79401
October 2022
Month Year
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.
TX GEN ASO BPA (Rev. 06/22) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association page 14
ADDENDUM PG
PERFORMANCE GUARANTEES
The Performance Guarantees described herein shall apply to the Administrative Services Agreement (the
"Agreement") to which this Addendum is attached and have the same force and effect as the Agreement's
most current Fee Schedule, unless amended, replaced, or terminated by the parties to the Agreement in
writing.
All obligations, definitions, terms, conditions, promises, agreements, and language in the Agreement and
its most current Fee Schedule apply equally to the obligations, terms, conditions, promises, agreements,
and language in this Addendum PG and its most current Exhibit -PG
SECTION I
TIMING
A. The period for which the Claim Administrator's performance will be measured and for
which Employer may receive a refund is referred to as the Settlement Period and is
indicated on the most current Exhibit -PG
B. The measurement of Performance Guarantees will begin on the date indicated on the
most current Exhibit -PG provided all of the requirements listed below are completed.
The requirements are as follows:
Benefit information and claims administrative procedures have been provided by
Employer to the Claim Administrator,
2. All accumulation totals, if applicable, have been received from the prior carrier and
have been loaded onto the Claim Administrator's claims processing system,
3. Accurate and complete membership information has been received and loaded onto
the Claim Administrator's claims processing system, and
4. Transfer Payment procedures have been established in accordance with the
Agreement.
SECTION II
DETERMINATION
A. The Claim Administrator agrees to guarantee performance levels as indicated on the most
current Exhibit -PG. In the event that the Claim Administrator's level of performance is
determined to be less than any of the standards described in the most current Exhibit -PG
during a Settlement Period for which the Claim Administrator's performance shall be
evaluated for any reason, except any disaster or epidemic which substantially disrupts the
Claim Administrator's normal business operation, the Claim Administrator will be
responsible for reimbursing Employer a portion of the Administrative Charge.
B. The Claim Administrator will measure Performance Guarantees and report the
measurement results to Employer, and any refund amounts due in accordance with this
Page 1
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives,
except under written agreement.
Addendum PG within 120 days following the close of all measurement periods necessary
to finalize Performance Guarantee results for the Settlement Period.
C. The Claim Administrator will not be obligated to measure Performance Guarantees and
will not be obligated to refund Employer based thereon until the Administrative Services
Agreement (including the most current Exhibit -PG) has been executed and is on file with
the Claim Administrator by the close of the applicable Settlement Period.
D. The Claim Administrator will not be obligated to measure Performance Guarantees and
will not be obligated to refund Employer based thereon for any portion of the Settlement
Period in which the Employer:
1. Fails to provide the Claim Administrator with Timely changes in enrollment or
membership information or any other reports or information as may be necessary for
the Claim Administrator to perform its administrative duties, including but not
limited to identification or certification of claimants eligible for benefits, dates of
eligibility, number of employees and dependents covered under the Plan; or
2. Fails to pay Administrative Charges in accordance with the terms of the Agreement
or comply with all established Transfer Payment procedures.
E. The Claim Administrator will not be obligated to measure any Performance Guarantee
impacted by changes requested in writing by Employer during the time period required to
modify the Claim Administrator's system and to complete all other tasks necessary to
achieve the same qualitative standard of execution that existed before the change was
requested. All changes or amendments to the Plan must be submitted to the Claim
Administrator in accordance with the Agreement.
F. If for any reason there is a significant change in the benefit structure or the administrative
procedures of the benefit coverage administered by the Claim Administrator, Medicare
payment systems, or if the enrollment of the Plan's benefit coverage administered by the
Claim Administrator varies in number of enrolled Covered Employees as indicated in the
most current Exhibit -PG attached to and made a part of this Addendum during any
Settlement Period, the Claim Administrator reserves the right to re-evaluate and
renegotiate the level of performance and/or the Administrative Charges at risk in this
Addendum PG and the attached Exhibit -PG..
G. If for any reason the Agreement is terminated prior to the end of any Settlement Period,
the Performance Guarantees will not be measured and Employer will not receive any
refund, based on that part of the Settlement Period in which the Administrative Services
Agreement was in effect.
H. If (i) changes to the formula, methodology or manner in which a third -party benchmark
(such as AWP) is calculated or reported take effect, or (ii) such third party ceases to
publish such benchmark, then the performance guarantees and/or standards based on
such benchmark in this Agreement, if any, shall be re-evaluated and adjusted or
converted to an alternative benchmark by Claim Administrator or its designee at the time
of such change to return the parties to their respective economic positions with respect to
such guarantees and/or standards as they existed under the Agreement immediately prior
to such change.
Page 2
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives,
except under written agreement.
PRESCRIPTION DRUG PROGRAM EXHIBIT -PG
EMPLOYER NAME: CITY OF LUBBOCK
Employer Account Number: 010097
Employer Group Numbers: 219476
Effective for the Settlement Period beginning January 1, 2023, and ending December 31, 2023
Effective for the Settlement Period beginning January 1, 2024, and ending December 31, 2024
Effective for the Settlement Period beginning January 1, 2025, and ending December 31, 2025
Effective for the Settlement Period beginning January 1, 2026, and ending December 31, 2026
Effective for the Settlement Period beginning January 1, 2027, and ending December 31, 2027
Performance guarantees are contingent upon adherence to the terms and conditions of Addendum -PG to which this Exhibit is attached and maintaining an enrollment in the Plan
prescription drug program benefit coverage administered by Claim Administrator of not less than 2,248 Covered Employees, based on a total of 2,498 contracts. Performance
measurement will begin January 1, 2023. Performance Guarantees are measured annually unless otherwise noted. Performance Guarantees are reported and settled on an annual basis
only.
SERVICE -
PRESCRIPTION DRUG
Defined Performance Guarantees
Performance
Guarantee
Dollars at Risk
Ongoing Service
Eligibility Updates means that 990o of ongoing eligibility updates shall be processed within
9900 - 10000
$0
five (5) business days of receipt of properly formatted and complete eligibility file. Measured
95% - 980•0
$1,000
quarterly on an Employer specific basis.
940o or less
$2,000
Eligibility Error Report is an error report on eligibility file updates that will be provided
0 - 5 days
$0
within five (5) business days of receiving updates. Measured quarterly on an Employer
6 days or greater
$2,000
specific basis.
Plan Administration Accuracy means new and revised benefits shall be setup without issue.
98% - I00%
$0
Setup issues are defined as production variance against BET submissions as identified via
96% - 97%
$1,000
audit activity. Prime guarantees an accuracy rate for all Benefit Plan setups. Excluded from
95% or less
$2,000
PG are benefit setup issues that are a result of erroneous or misinformed client direction or
BET submissions. Member benefit setup errors will be counted in the month and year they
are confirmed to be an error. The percent accuracy will be measured by using member
impact. Measured quarterly at the Blue Plan book of business basis.
Retail Network Program
Average Speed of Answer is defined as the time a Caller spends on hold, after being placed
0 - 30 seconds
$0
in queue, until a service representative becomes available. Standard is measured by
31 seconds or greater
$2,000
determining the average number of seconds the Caller spends waiting for a service
representative, calculated over the complete workday. Measurement is based on calls from
those customers assi ned to the Unit.
City of Lubbock 2023-2027 PDP PG Exhibit v3 Page 1 of 4 9 28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except under written agreement
SERVICE -
PRESCRIPTION DRUG
Defined Performance Guarantees
Performance
Guarantee
Dollars at Risk
Abandoned Calls are defined as Calls, calculated over the complete workday, that reach the
000 - 300
$0
facility and are placed in a queue, but are not answered because the Caller hangs up before a
400 or greater
$2,000
service representative becomes available. Measurement is based on calls from those
customers assigned to the Unit.
RxClaim System Availability 99.750o measured 24 hours a day, 7 days a week based on
99.75% - 100%
$0
Prime's book of business. Reports of unplanned downtime (planned downtime is excluded)
99.74% or less
$2,000
from Prime's service management ticketing system will be utilized for reporting the
availability of key systems. Excludes any occurrence of power outages; downtime occurring
during the scheduled maintenance window; hardware, software, network or communications
failure beyond Prime's control; and downtime/availability experienced by HCSC.
Claims Processing Accuracy - 99% of Claims will be adjudicated accurately. A random
99% - 10000
$0
audit of adjudicated claims will occur monthly and will be validated against the Benefit Edit
98% or less
$2,000
Tool submissions and test claims. Measured annually at the Blue Plan book of business basis.
Paper Claim Turn Around Time means that within fourteen (14) business days, 99% of al l
99% - 10000
$0
paper claims not requiring clarification shall be processed. Measurement does not include
98% or less
$2,000
payment. Measured annually at the Blue Plan book of business basis.
Geographic Access Network Members will have access to Network Participants for
90%- 10000
$0
covered prescription drug services. Measured at the Blue Plan book of business level.
890 0 or less
$2,000
Geographic Access means the Claims Administrator guarantees that a Network Participant
will be within two (2) miles of a Member in an urban area 90°•0 of the time.
Note These networks do not apply to limited networks, only broad networks.
Geographic Access Network Members will have access to Network Participants for
90% - 100%
$0
covered prescription drug services. Measured at the Blue Plan book of business level.
89% or less
$2,000
Geographic Access means the Claims Administrator guarantees that a Network Participant
will be within five (5) miles of a Member in a suburban area 900,o of the time.
Note These networks do not apply to limited networks, only broad networks.
Geographic Access Network Members will have access to Network Participants for
700, - 1000 0
$0
covered prescription drug services. Measured at the Blue Plan book of business level.
690 0 or less
$2,000
Geographic Access means the Claims Administrator guarantees that a Network Participant
will be within fifteen (15) miles of a Member in a rural area 700 0 of the time.
Note These networks do not apply to limited networks, only broad networks.
City of Lubbock 2023-2027 PDP PG Exhibit v3 Page 2 of 4 9 28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except under written agreement
SERVICE -
PRESCRIPTION DRUG
Defined Performance Guarantees
I
Performance
I Guarantee
Dollars at Risk
Mail Service Program
Turnaround time for routine prescriptions is defined as the processing time for mail
96"o - 1000u
$0
ESI
service prescriptions. Measurement is based on the processing time from the date received to
95oo or less
$2,000
the date shipped. The performance guarantee will be measured as a percent of clean
prescriptions processed within 2 business days. Measured at the Blue Plan book of business.
Turnaround time for non -routine prescriptions is defined as the processing time for mail
9800 - 10000
$0
service prescriptions. Measurement is based on the processing time from the date the order
970•u or less
$2,000
was received to the date the order was shipped. The performance guarantee will be measured
as a percent of prescriptions requiring intervention processed within 5 business days.
Intervention means additional information is required before the document claim or
prescription can be processed. Measured at the Blue Plan book of business.
Prescription (Mail) Dispensing Accuracy Overall mail service pharmacy accuracy rate of
99.9900 - 10000
$0
99.99°o. An error will include incorrect patient, incorrect directions, incorrect strength, or
99.980o or less
$2,000
incorrect medication in the container. Notwithstanding the foregoing, an error will not include
immaterial matters such as generic substitution not addressed, incorrect spelling of a plan
member's name on the label, or incorrect spelling of a physician's name.
Accuracy is determined by dividing the total number of errors by the total number of
prescriptions shipped for its book of business. Measured at Prime's book of business.
Mail Service Member Satisfaction - A survey of Prime Members who have received Covered
9000 - 10000
$0
Drugs from ESI Mail Pharmacy will be completed quarterly by Pharmacy specific to Prime on a
890 o or less
$2,000
Prime Book of Business basis. Pharmacy guarantees a Prime Member satisfaction rate of 90° o
based on overall satisfaction. Guarantee assumes the number of responses is statistically
significant provided Pharmacy makes commercially reasonable efforts to obtain responses from a
statistically significant number of Prime Members. The survey will focus on the end -to -end
Home Delivery experience. Measured at Prime's book of business.
Specialty Service Program
Delivery Success Rate for Specialty Medications means that 99.800 of Specialty Drug
99.8% - 100%
$0
Accredo
orders will be delivered to the Prime Member within the agreed upon delivery date (i.e., Need
99.7"o or less
$2,000
by Date). Includes Clean Orders but excludes orders where the Prime Member and/or the
physician requested that Pharmacy change the date. Measured at the Blue Plan book of
business. If minimum volume of 20k specialty prescriptions per year is not met, measured at
Prime's book of business.
City of Lubbock 2023-2027 PDP PG Exhibit v3 Page 3 of 4 9/28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator. Employer, their respective affiliated companies and third party representatives, except under written agreement.
SERVICE -
PRESCRIPTION DRUG
Defined Performance Guarantees
Performance
Guarantee
Dollars at Risk
Specialty Service Member Satisfaction - One survey of Prime Members who have received
Specialty Drugs from Accredo Specialty Pharmacy will be completed quarterly by Pharmacy
90% - 100%
$0
on the Operating Unit level. Pharmacy guarantees a Specialty Prime Member satisfaction rate
89% or less
$2,000
of 900u based on overall satisfaction and the responses represent a statistically significant
number. Measured at the Blue Plan book of business. If minimum volume of 20k specialty
prescriptions per year is not met, measured at Prime's book of business.
Total PDP
$34,000
IN WITNESS WHEREOF, the parties have executed this Exhibit -PG to remain in effect for the indicated period of time.
BLUE CROSS AND BLUE SHIELD OF TEXAS, a Division of
Health Care Service Corporation, a Mutual Legal Reserve
Company
XC L.-- ,71. .S, L'—
Kathy Selck
Please Print Name
Title: Vice President & Chief Underwriter
CITY OF LUBBOCK
Title: Mayor
Tray Payne
Please Print Name
Date: September 28, 2022 Date: nrtaher 1 1 ?027
City of Lubbock 2023-2027 PDP PG Exhibit v3 Page 4 of 4 9. 28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third party representatives, except under written agreement
EXHIBIT -PG
EMPLOYER NAME: CITY OF LUBBOCK
Employer Account Number: 010097
Employer Group Number(s): 219476
Effective for the Settlement Period beginning January 1, 2023, and ending December 31, 2023
Effective for the Settlement Period beginning January 1, 2024, and ending December 31, 2024
Effective for the Settlement Period beginning January 1, 2025, and ending December 31, 2025
Effective for the Settlement Period beginning January 1, 2026, and ending December 31, 2026
Effective for the Settlement Period beginning January 1, 2027, and ending December 31, 2027
Performance guarantees are contingent upon adherence to the terms and conditions of Addendum -PG to which this Exhibit is attached and maintaining an enrollment in the Plan medical
benefit coverage administered by Claim Administrator of not less than 2,248 Covered Employees based on a total of 2,498 contracts. Performance measurement will begin January 1,
2023. Performance Guarantees are measured and settled annually.
Percentage
SERVICE — Medical
Defined Performance Guarantees
Performance
of the
Guarantee
Administrative
Charge at Risk
Account Management
Account Management means the Employer's satisfaction with Account Management and will
Composite Score
be measured by the Employer, using the Claim Administrator's Account Management Client
3.0 - 5.0
Oou
Satisfaction Survey.
0 - 2.9
2n.o
Claims Processing
Claims Processing Turnaround Time means the period beginning on the date the Claim
90.0% - 100%
0°o
Turnaround Time
Administrator or Host Blue receives a Claim for processing through the date the Claim passes all
88.0% - 89.9%
l o o
Process -Ready Claims
system edits and benefits are approved or denied by the Claim Administrator. The performance
0%- 87.9%
20o
guarantee is measured as a percent of process -ready Claims processed within 14 calendar days.
Method of Measurement: The number of process -ready claims processed in 14 calendar days
divided by the total number of process -ready claims. Process -ready means a Claim that, when
received by the Claim Administrator, contains all of the Claim information required to process
the Claim. Measurement is based on Employer -specific Claims.
Claims Processing
Claims Processing Turnaround Time means the period beginning on the date the Claim
97.00o - 100°%
0o/u
Turnaround Time All
Administrator or Host Blue Plan receives a Claim for processing through the date the Claim
95.0% - 96.9%
1%
Claims
passes all system edits and benefits are approved or denied by the Claim Administrator. The
096- 94.9°%
2%
performance guarantee is measured as a percent of all Claims processed within 30 calendar days.
Method of Measurement: The number of Claims processed in 30 calendar days divided by the
total number of claims. Measurement is based on Em to er-s cific Claims.
City of Lubbock 2023-2027 Medical PPO PG Exhibit v3 Page I of 4 9/28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except under written agreement.
SERVICE — Medical
Defined Performance Guarantees
Performance
Guarantee
Percentage
of the
Administrative
Charize at Risk
Claim Processing Accuracy
Claim Processing Accuracy is defined as the percent of Claims processed accurately in
97.0% - 100%
000
accordance with the provisions of the medical benefit coverage administered by the Claim
95.0°% - 96.9%
1 ° o
Administrator. Claim Processing Accuracy refers to Claims without processing errors such as:
0% - 94.9%
20o
1. Coding - incorrect claim data entry.
2. Failure to adhere to the Employer's health care benefit program design.
3. Failure to adhere to the administrative procedures.
4. System generated errors, benefit programming errors, calculation errors.
5. Excluding:
a. Any administrative inaccuracies that do not impact claims disposition or customer
reporting;
b. Errors entered by providers of service;
c. Benefits provided to an ineligible claimant due to the Employer's failure to provide
timely and accurate eligibility information to the Claim Administrator.
Method of measurement: The accuracy rate is determined from a statistically valid random
stratified sample audit of all Claims processed during the settlement period. A Claim Processing
Accuracy percentage is calculated for each stratum by dividing the number of accurately
processed Claims by the number of Claims selected in the stratum. Each accuracy percentage is
then weighted according to the total claim population. The Claim Processing Accuracy rate is
determined by summing the weighted accuracy from each stratum. Measurement is based on an
audit of Claims processed for those customers assigned to the Unit.
Claim Financial Accuracy
Claim Financial Accuracy means the percent of dollars paid accurately in accordance with the
98.0% - l00%
0° o
provisions of the medical benefit coverage administered by the Claim Administrator.
97.0% - 97.9%
I ° o
0%-96.9%
200
Method of measurement: The accuracy rate is determined from a statistically valid random
stratified sample audit of all Claims paid during the Settlement Period. Total dollars overpaid
and total dollars underpaid are projected over each stratum. Claim Financial Accuracy is
computed by summing the projected overpayments and the projected underpayments (absolute
value) from each stratum and dividing by the total dollars paid in the population. The end result
is subtracted from one for the accuracy rate. Measurement is based on an audit of Claims
processed for those customers assigned to the Unit.
City of Lubbock 2023-2027 Mcdical PPO PG Exhibit v3 Pagc 2 of 4 9/28 2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except under written agreement
Percentage
SERVICE — Medical
Defined Performance Guarantees
Performance
of the
Guarantee
Administrative
Charge at Risk
Customer Service
Inquiry Resolution is defined as number of days it takes to resolve a participant inquiry,
95.0% - 100%
0%
beginning with the date the inquiry is received to the resolution date. All written and telephone
94.0%- 94.9%
1%
inquiries will be measured. The standard is measured as a percent processed within 14 calendar
0% - 93.9%
2%
days on an Employer -specific basis.
Average Speed of Answer of Telephone Calls, calculated over the complete business day, is
0 - 30 seconds
0%
defined as the time a caller spends on hold until a customer advocate becomes available.
31 - 60 seconds
1%
61 seconds or more
2%
Method of measurement: The average speed of answer will be calculated by dividing the total
length of time for all calls, measured from the time a call is queued by the automated telephone
system for the next available customer advocate until the time the caller is connected with a
customer advocate, by the total number of calls connected with a customer advocate during the
Settlement Period. The Average Speed to Answer is provided by telephone reports that compute
the average number of seconds that Callers spend on hold waiting for their Call to be answered.
Standard is measured using member calls on an Employer -specific basis.
Abandoned Calls are defined as calls, calculated over the complete business day, that reach the
0% - 3.0%
000
facility and are placed in a queue, but are not answered because the caller hangs up before a
3.1 % - 5.0%
100
customer advocate becomes available. Any calls abandoned or terminated by the caller prior to
5.1 % - 100%
20 o
30 seconds will not be counted as Abandoned Calls. Standard is measured using member calls
on an Employer -specific basis.
Customer Satisfaction
Customer Satisfaction is defined as the percent of the enrolled members who respond to the
80.0% - 100%
0%
Commercial Member Satisfaction Survey (CTP 2.0), rating the overall performance of their
75.0% - 79.9%
1%
health plan as Excellent, Very Good, or Good.
0% - 74.9%
2%
Standard is measured based on statistically valid sample of Covered Persons under the Claim
Administrator's PPO program.
Total Medical
18%
City of Lubbock 2023-2027 Medical PPO PG Exhibit v3 Page 3 of 4 9/28 2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except under written agreement
IN WITNESS WHEREOF, the parties have executed this Exhibit -PG to remain in effect for the indicated period of time.
BLUE CROSS AND BLUE SHIELD OF TEXAS, a Division of CITY OF LUBBOCK
Health Care Service Corporation, a Mutual Legal Reserve
Company
)4j_ - fi. �a
KathySelck
Please Print Name
Please Print Name
Title: Vice President & Chief Underwriter Title: Mayor
Date: September 28, 2022 Date: October 11, 2022
City of Lubbock 2023-2027 Mcdical PPO PG Exhibit v3 Page 4 of 4 9/28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -party representatives, except under written agreement.
DENTAL EXHIBIT -PG
EMPLOYER NAME: CITY OF LUBBOCK
Employer Account Number: 010097
Employer Group Number(s): 106837
Effective for the Settlement Period beginning January 1, 2023, and ending December 31, 2023
Effective for the Settlement Period beginning January 1, 2024, and ending December 31, 2024
Effective for the Settlement Period beginning January 1, 2025, and ending December 31, 2025
Effective for the Settlement Period beginning January 1, 2026, and ending December 31, 2026
Effective for the Settlement Period beginning January 1, 2027, and ending December 31, 2027
Performance guarantees are contingent upon adherence to the terms and conditions of Addendum -PG to which this Exhibit is attached and maintaining an enrollment in the Plan dental
benefit coverage administered by Claim Administrator ofnot less than 2,237 Covered Employees, based on a total of 2,485 contracts. Performance measurement will begin January 1,
2023. Performance Guarantees are measured and settled annually.
Percentage
of the Dental
SERVICE - Dental
Defined Performance Guarantees
Performance
Administrative
Guarantee
Charge at Risk
Claim
Claim Turnaround Time - Turnaround time is defined as the number of days it takes to
90.00.0-100"o
0°0
Turnaround Time
process a claim, beginning with the date the claim is received to the check/EOB date on
0%-89.9%
20o
participant filed claims or to the date the claim passes all edits on provider filed claims. The
standard is measured as a percent of process -ready claims finalized within 14 calendar days
on an Employer specific basis.
Claim
Processing Accuracy is defined as the percent of claims processed accurately. The level of
97.0%-100%
000
Processing Accuracy
performance is based on the results from a random sample audit of all claims processed for
0%-96.9%
200
those customers assigned to the Unit.
Claim
Financial Accuracy is defined as the percent of dollars paid accurately. The level of
98.0%-100%
09'o
Financial Accuracy
performance is based on the results from a random sample audit of all claims processed for
0%-97.9%
2%
those customers assigned to the Unit.
Inquiry Resolution
Inquiry Resolution - Inquiry resolution is defined as the number of days it takes to resolve a
95.0%-1009'u
000
participant inquiry, beginning with the date the inquiry is received to the resolution date. All
0%-94.9%
2tio
written and telephone inquiries will be measured. The standard is measured as a percent
processed within 14 calendar days for those customers assigned to the Unit.
City of Lubbock 2023-2027 Dental PG Exhibit v3 Page 1 of 3 9/28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and third -parry representatives, except under written agreement
Percentage
of the Dental
SERVICE - Dental
Defined Performance Guarantees
Performance
Administrative
Guarantee
Charge at Risk
Abandoned Calls
Abandoned calls are defined as calls, calculated over the complete workday, that reach the
0%-3.0%
000
facility and are placed in a queue, but are not answered because the caller hangs up before a
3.1%-100%
20o
service representative becomes available. Any calls abandoned or terminated by the caller
prior to the Average Speed to Answer number of seconds standard will not be counted as
Abandoned Calls. Standard is measured using participant calls for those customers assigned
to the Unit.
Average Speed to Answer
Average Speed to Answer, calculated over the complete workday, is defined as the time a
0-30 seconds
00 0
caller spends on hold until a service representative becomes available. Standard is measured
31 seconds or more
20 o
by determining the average number of seconds the caller spends waiting for a service
representative. Standard is measured using participant calls for those customers assigned to
the Unit.
Total Dental
12%
City of Lubbock 2023-2027 Dental PG Exhibit v3 Page 2 of 3 9/28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their respective affiliated companies and thud -party representatives, except under written agreement
IN WITNESS WHEREOF, the parties have executed this Exhibit -PG to remain in effect for the indicated period of time.
BLUE CROSS AND BLUE SHIELD OF TEXAS, a Division of CITY OF LUBBOCK
Health Care Service Corporation, a Mutual Legal Reserve
Company
Kathy Selck
Please Print Name
Title: Vice President & Chief Underwriter Title: Mayor
Date: September 28, 2022 Date: October 11, 2022
City of Lubbock 2023-2027 Dental PG Exhibit v3 Page 3 of 3 9/28/2022
Proprietary Information
Not for use or disclosure outside Claim Administrator, Employer, their rcspeehve affiliated companies and third -party representatives, except under written agreement
09 BlueCross B1ueShield PBM Fee Schedule Addendum to the Benefit Program Appi canon
of Texas
ary of Lubbock
Exceba Dan: 0102 zoz3
Members! 5,383
Err1 loyeo: 2,470
-C - =7�
Contract Period
PASSTHROUGH Pkrc&G
Advantage
RehR Network
1/2/2023 to 12/31/2023
19.50%
2/2/2024 to 12/31/2024
19.55%
1/1/2025 to 12/31/2025
19.10%
Extended
Network
ESN) -90 Day
Channel
1/1/2023 to 12/31/2023
22.45%
1/1/2024 to 12/31/2024
22.55%
1/1/2025 to 12/31/2025
22.65%
Man
1/1/2023 to 12/31/2023
24.30%
1/1/2024 to 12/31/2024
24.30%
1/2/2025 to 12/3t/2025
24.30%
Retain Network
1/1/2021 to 12/31/2023
$6.80%
1/1/2024 to 12/31/2024
$6.90%
1/1/2025 to 1U31/2025
87.00%
Extended Supply Network (ESN) - go Day Channel
1/1/2023 to 12/31/2023
88.70%
1/1/2024 to 12/31/2024
88.90%
1/1/2025 to 12/31/2025
88.90%
Man
1/1/2023to 12/31/2023
86.45%
1/1/2024 to 12/31/2024
86.55%
1/1/2025 to 12/31/2025
86.65%
Redo Network
1/1/2023 to 12/31/2023
S0.40
1/1/2024 to 1'31/2024
$0.40
1/2/2025 to 12/31/2025
50.40
ExcandM
Network -90 OW
Channel
1/1/2023 to li/31/2023
50.00
1/1/2024 to 12/31/2024
$0.00
1/1/2025 to 12/31/2025
50.00
Man
1/1/2023 to 12/31/2023
$0.00
1/1/2024 to 12/31/2024
$0.00
1/1/2025 to 12/31/2025
$0.00
Ratan Network
1/1/2023 to 121 112023
$0,40
1/1/2024 to 12/32/2024
$0.40
1/1/2025 to 12/31/2025
$0.40
Extended
Network
ESN -90 Day Channel
1/1/2023 to 12/31/2023
$O,pp
1/1/2024 to 12/31/2024
50.00
1/1/2025 to 12/31/2025
$0.00
Man
1/1/2023 to 12/31/2023
$0,00
1/1/2024 to 12/31/2024
$0.00
1/2/2025 to 12/3t/2025
$0.00
Discount
1/1/2023 to 12111/'0'3
24.00%
1/1/2024 to 12/31/2024
24.00%
1/1/2025 to 12/31/2025
24.00%
Specialty Ph.DispensingFee
1/1/2023 to 22/3t/2023
So.o0
1/1/2024 to 22/3t/2024
50.00
1/1/2025 to 12/31/2025
$0,00
Notes:
- Discounts are based on the actual NDC-11 dispensed on the fill date.
- Guarantees are based upon the above selected BOBS TX Network.
• Guarantees are based upon an Implemented $CBS TX Extended Supply Network (90-day retail). If not implemented, Retail rates apply.
• For the purpose of reconciliation at contract year end, discount and dispensing fee guarantees are reconciled in aggregate, as long as the
contract remains in effect.
- Discount and dispensing fee rates exclude compound, long term care (LTC) pharmacy, home mfusion (NIF) pharmacy, veterans affairs (VA) pharmacy,
Indian/tribal/urban Q/T/U) pharmacy, 3408, Medicare/Medl-d. outaf-network, member -submitted, foreign, coordination of benefits (COB), 100%
member -paid plans (..e. discount cards not including MedsYourWay drug discount card program), subrogation, paper, invalid, usual and customary (U$C)
claims and non -specialty discount and dispensing fees also exclude specialty (as defined by the BOBS TX specialty drug pricing fie) cla ms.
- For discount purposes, Specialty is defined by the BOBS TX specialty drug pricing file.
-Guarantees are based upon a exclusive specialty network arrangement
-Aggregate Spec airy discount guarantees do not include Imlted distribution drugs (LDDs) nor any new specialty drugs brought to market and
added to the specialty list dur ng the term of each contract year
• For discount and dispensing fees, Brand drugs are defined as drugs that have a Medi-Span multlsource code field equal to'M",'N', or'O'
• For it scount and dispensing fees, Generic drugs are defined as drugs available in sufficient supply that have a Medi-Span multisource code field
equal to'Y'
• Compound Cie ms, Foreign Claims, reversed claims, and outcf•network clams are excluded from the calculation of whether the AWP discounts
and Dispeno ng Fees shown above have been achieved and also are exduded from the calculation of any shortfall credit for Employer
09/28/2022
"NCSC GEN ASO PBM Custom Fee Addendum 09/17" Page 1 of 3
BlueCross B1ueShield PBM Fee Schedule Addendum to the Benefit Program Application
of Texas
4N of Wbback
Elfectlu Data• 01101r2023
Members r 5,393
Employ—. Z470
Contract Period
varMmnana
Retag Nel cork
1/1/2023 to 12/31/2023
$241.58
vino21l to 12/31/2024
$281 69
1/1/2025 to 22/31/2025
$305.61
Ed"Witd Netwwrki -90
Channal
1/1/2023 to 12/31/2023
$698 58
1/1/2024 to 12/31/2024
$750 70
1/1/2025 to 12/31/2025
$907 15
Mau
1/1/2021 to 12/31/2023
$670 30
1/1/2024 to 12/31/7024
$697 85
1/11025 to 12/31/2025
$722.24
1/1/2023 to 11/31/2023
$2,887.79
1/1/2024 to 12/31,2024
$3,443 72
1/1/2025 to 12/31/2025
$3,98140
1/1/2023 to 12/31/2023
$92.13
1/1/2024 to 12/31/2024
$110 26
1/1/2025 to 12/31/2025
$131 91
Notes:
- Rebates will be trued up annually to the greater of the PEPM rebate credits, per brand Rx rebate guarantees. and actual rebatr.
- Rx offer is contingent on BOBS Tx being the medical benefits administrator
- For rebate purposes, Specialty Is defined by the BCBS Tx specialty drug pricing file
- For the purpose Of reconciliation at contract year end, all rebate guarantees are reconciled in aggregate as ong as the contract remains -n effect.
• Compound, long term care (LTC) pharmacy, home Infusion (HIF) pharmacy, veterans affairs (VA) pharmacy, Indian/R bal/urban il/Tljl pharmacy,
340b, Medicare/Medioid, out of network, member -submitted, foreign, coordination of benefits (COB), 100% member -pa, d plan (i.e. discount
4ardl, subrogation, paper, Invalid, vaccine, over-the-w unter (OTC), Fero balance due (100%member paid), bloslmllar, and I mated distribution
drug (LOD) claims are excluded from rebate guarantees.
For rebate purposes, Brand drugs are defined as all drugs that have a MednSpan multisource code field equal to'M','N', or'0'
09/29/2022
'XCSC GEN ASO PBM Custom Fee Addendum 09117" Page 2 of 3
09 B1ueCross B1ueShield PBM Fee Schedule Addendum to the Benefit Program APPgcatlon
of Texas
City of Lubbock
Effective Data: 01/01/2023
Members: 5,383
Employ—: 2,470
F. CUSTOM PASSTHROGGHM-1—CM;
Contract Period Per Emfsbyaa Par Month
1/1/2023 to 12/31/2023 $4.57
1/1/2024 to IV 1/2024 $4.57
1/2/20.25 to 1':1/2025 54.57
Notes:
- Administrative Fees will be charged at the above rate on a per employee per month bavt
Additional Caveats:
-Guarantees are based on adoption and adherence of an above BCBS TX drug 119, Including associated utilization management
and clinical programs. BCBS TX reserves the right to equitably adjust guarantees for the following: changes In any law or regulation,
changes In interpretation of a law or regulation, changes within PBM marketplace which lead to a significant deviation from the current
economic environment, unexpected market events, unexpected generic launches, authorized generic launches, blosimilar launches, products
launched at risk, products under patent litigation, new lower cost NDCs priced net of rebates from the Innovator, products with AWP decreases,
implementation of new clinical programs, removal of existing clinical programs. changes in pharmacy benefit pan desigrk or drug zst changes.
Members will pay the lower of the contracted rate, UBC, or their applicable copayment. Zero balance logic is not employed.
- Assumes client does not have 340E pricing.
- Guarantees provided does not Include savings from DUA or other dinical programs.
• Specialty drugs dispensed through the medial benefit will not be Included In reconciliation of guarantees
• Guarantees assumes 26%ESN penetration, If that differs significantly, BCBS TX reserves the right to revise guarantees terms and financials.
- Guarantees assumes I% Mall penetration, If that differs significantly, BCBS TX reserves the r, ght to revise guarantees terms and finand a s.
- BCBS TX reserves the right to equitably adjust the guarantees In the event the number of covered members or p^ armacy dal ms volume
materially changes over the course of the contract.
- Covid-19 related testing, vaccines, and treatments are excluded from guarantee reconcil lotion.
- Members' cost share Is the applicable copayment, deductible, and/or coinsurance, which coinsurance is calculated in accordance with the
applicable Network Contract or the applicable ouW-network pricing Zero balance logic is not employed.
- Employer will be billed for Foreign Claims in an amount based on the amount billed by the pharmacy.
-Employer will be billed for out -of -network claims based on the pricing set forth in the Administrative Services Agreement and/or PBM Exhibit, as
applicable.
• Guarantees will be calculated as described in this Addendum and the PBM Exlstill t to the Administrative Services Agreement
• Unless otherwise specified In this Addendum, capitalized terms used,n th,s Addendum shall have the meanings set forth the Admi+Istrative
Services Agreement or the PBM Exhib t, as applicable
Mayor
Title
October 11, 2022
Date
09/28/2022
'NCSC GEN ASO PBM Custom Fee Addendum 09/17" Page 3 of 3
BlueCare® Freedom Dental
1bBlueCross BlueSWeld
. V of Texas
DENTAL BENEFIT HIGHLIGHTS Prepared for City of Lubbock
Effective 01 /01 /2023
ALL FIELDS BELOW ARE REQUIRED TO BE COMPLETED
Type of
General Provisions
❑ Plan ® Calendar Year Deductible If applicable, deductible option should mirror medical $75 Individual I $225 Family
deductible option. (Remove before distribution)
Three-month Deductible carryover applies (Not applicable if Plan Year Chosen) Yes
Deductible credit from prior carrier No
Maximum per Participant $1200
Diagnostic and Preventive Care Benefits
®Deductible Waived (standard)
❑Deductible Not Waived
Oral Examinations (2 exams per Year)
Prophylaxis (2 cleanings per Year)
Fluoride Treatment (to age 19; 2 per Year)
Dental X-rays (Subiect to booklet provision) — Full Mouth/Panoramic Xrays —1 time Der 36 months
Miscellaneous Services
®Deductible Waived
❑Deductible Not Waived (standard)
Sealants (up to age 16; applies to permanent molars, one application per tooth, per lifetime)
Space Maintainers (up to age 19)
Labs and Tests
Restorative Services
Amalgams and Composites
Simple Extractions
100%
100%
80%
General Services
Anesthesia 80%
Stainless Steel Crowns
Endodontic Services
Root canal therapy
Direct pulp cap
Apicoectomy/Apexification
Retrograde filling/Root amputation/hemisection 80%
Therapeutic pulpotomy/Gross pulpal debridement
Periodontal Services
Periodontal scaling and root planning
Full mouth debridement/Periodontal Maintenance
Gingivectomy/Gingivoplasty
80%
Oral Surgery Services
Surgical tooth extractions
AlveoloplastyNestibuloplasty 80%
Crowns, Inlays/On/ays Services
Prefabricated post and cores I 50%
Recementation of crowns, inlays/onlays
Crown Repair 1 80%
Prosthodontic Services
Reline/Rebase
Bridges and dentures 50%
Recementation and Repair of Bridges
Orthodontic Benefits
®Deductible Waived (standard)
❑Deductible Not Waived
Orthodontic Diagnostic Procedures and Treatment:
Adults eligible: ❑ No ® Yes - If yes, indicate age limitation: 26 50%
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
BlueCare Freedom Dental for Groups Sold after 07/01/2012 (Revised 6/2015) Page 1 of 3
BlueCare® Freedom Dental
��B1ueCrossBlueSWeld
Of Texas
DENTAL BENEFIT HIGHLIGHTS Prepared for City of Lubbock
Effective 01 /01 /2023
ALL FIELDS BELOW ARE REQUIRED TO BE COMPLETED
Dependent Children eligible: ❑ No ® Yes - If yes, indicate age limitation: 26
Orthodontic Lifetime Maximum per Participant 1 $1,000
Additional Provisions(Please list any benefit changes,account structure changes, new benefit exclusion
and effective date of change):
Comments: Approved CBSR 2018-00580-Add language to first sentence:Under Right of Recover by Subrogation or Reimbursement -Your or your
Dependent agree to promptly furnish to the plan all information excluding any third party through uninsured or under insured motorist coverage which
you have concerning your right of recovery from any person, organization, or insurer and to fully assist and cooperate with the Plan in protecting and
obtaining its reimbursement and subrogation rights.
Definition of an Employee:
Employee means all regular full time employees of the Plan Sponsor are eligible to
participate in the Plan upon the completion of one full two -week pay period, except for
employees in the following categories:
Employees covered by a collective bargaining agreement to which the Plan Sponsor is a
party and which does not provide participation in the Plan;
Leased Employees within the meaning of Section 414(n) of the Internal Revenue Code;
Individuals who are classified by the Plan Sponsor does not withhold federal income and
employment taxes from such person's compensation;
Nonresident aliens who receive no earned income(within the meaning of Code Section 911
(d)(2)) from their employer that constitutes income from sources within Employees who
are not regularly scheduled to work at least 30 hours per week.
*'Each time you need dental care. you can choose to:
See a Contracting BlueCare Dentist
See a Non -Contracting Dentist
• Your out-of-pocket cost will generally be the least amount because BlueCare
• Your out-of-pocket cost may be greater because Non -Contracting Dentists have not
Dentists have contracted to accept a lower Allowable Amount as payment in
entered into a contract with BCBSTX to accept any Allowable Amount determination
full for Eligible Dental Expenses
as payment in full for Eligible Dental Expenses
• You are not required to file claim forms
• You are required to file claim forms
• You are not balance billed for costs exceeding the BCBSTX Allowable
• You are balance billed for costs exceeding the BCBSTX Allowable Amount
Amount for BlueCare Dentists
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
BlueCare Freedom Dental for Groups Sold after 07/01/2012 (Revised 6/2015) Page 2 of 3
BlueCare® Freedom Dental
EMPLOYEE INFORMATION
BlueCrosa BlueShield
of Texas
• This is a general summary of your benefit design. Please refer to your benefit booklet for other details and for limitations and exclusions.
• The following eligibility provisions apply:
• Dependent children are covered to age 26. Disabled dependent children can be covered beyond age 26.
• Retirees are not eligible for coverage.
• Employees may enroll dependent children up to age 5 on the first of the month following application with no late enrollment penalty.
• Open enrollment — employees and/or dependents not presently covered may enroll for dental 31 days prior to the anniversary date.
An exclusion will apply to expenses involving the replacement of teeth that were missing prior to the effective date of the dental contract. All other
benefits will begin on the first day of coverage. This exclusion will not apply to:
• Any participant who becomes effective on the dental contract date who was covered under a previous group dental care contract by the
Employer.
• Any participant who has been continuously covered for 24 months under a group dental care contract with BCBSTX which included
prosthetic benefits.
• A partial or full denture or fixed bridge which includes replacement of a missing tooth which was extracted after coverage becomes effective
Athletic mouth guards, isolation or tooth with rubber dam, metal copings, mobilization of erupted/malposition tooth, precision attachments for partials
and/or dentures and stress breakers are covered and payable at 50% after calendar year deductible. These services are subject to the $1200 annual
maximum
Tray Payne, Mayor
Group Executive Name and Title
(Please type or print)
Agent of Record Name
(Please print or type)
BCBSTX Representative Name Signature
(Please print or type)
October 11, 2022
Date
Date
Date
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield
Association
BlueCare Freedom Dental for Groups Sold after 07/01/2012 (Revised 6/2015) Page 3 of 3
BlueCross BlueShield
of Texas
EXHIBIT
I E
APPLICATION AND POLICY SCHEDULE FOR STOP LOSS COVERAGE
Employer Group Name:
Employer Group Address:
City:
Account Number:
Employer Group Number(s):
Original Effective Date of Stop Loss Policy
City of Lubbock
1314 Avenue K
Lubbock State of Situs: TX
010097
219476
01/01/2014
Zip Code: 79401
Current Policy Effective Date: 01/01/2023
Current Policy Period The specifications set forth in this Application are for the Policy Period commencing on 01/01/2023 and
ending on 12 31:2023.
The specifications below shall become effective on the first date of the Policy Period specified above and shall continue in
full force and effect until the earliest of the following dates: (1) The last day of the Policy Period; (2) The date the Policy
terminates; or (3) The date this Application is superseded in whole or in part by a later executed Application.
A. Covered Employees:
Number of Single Coverage Units: 1,258
Number of Family Coverage Units: 1,248
B. Individual Stop Loss Coverage:
1. New Coverage ❑ Renewal of Existing Coverage
2. Stop Loss coverage during the Current Policy Period
® 12/15
Coverage for Claims incurred from 01/01/2023 to 12/31/2023 and Claims paid from 01/01/2023 to 03/31/2024.
If 24/12, 18/12, 15/12, or 12/12 are selected, Employer Group understands that run -out coverage is not included,
and Employer Group represents that it intends to purchase run-in coverage from its next carrier.
For new coverage only, if a run-in contract as explained in the Stop Loss Policy (24/12, 18/12, or 15/12 coverage
period) is purchased, claims paid by the Employer Group's prior claim administrator will be settled at the time of
the annual stop loss settlement and must be reported by the Employer Group to the Company (Blue Cross and
Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company) by the
end of the Employer Group's Current Policy Period or stop loss coverage for these run-in claims will be forfeited.
❑ (Paid Renewal Only) Claim Administrators Claims: Claims incurred on or after the Original Effective Date of
Policy and paid during the Policy Period.
3. Covered Expenses includes:
® Medical Claims:
® Prescription Drug Claims with: Prime (Preferred PBM)
TX SL-APP Rev. 3.21
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company
an Independent Licensee of the Blue Cross and Blue Shield Association
❑ For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
❑ Other (for example Dental/Vision):
4. Individual Stop Loss Provisions
a. Individual Stop Loss Deductible: $700,000
Applies per Covered Person for the Employer Group's Current Policy Period.
b. Aggregating Specific Deductible (if applicable): $
c. Lasered Individuals with Individual Stop Loss Deductible (if applicable):
Individual identifier, alternate Individual Stop Loss Deductible:
d. Lasered Individuals excluded from Stop Loss Coverage (if applicable):
Individual identifier:
e. If a run-in contract (24/12, 18/12, or 15/12 coverage period) is purchased, per Item 2. above, run-in
claims are covered with a maximum liability of: $Unlimited per Covered Person.
5. Terminal Liability Option (TLO) (does not apply to Employer Groups with 12/15, 12/18, or 12/24 contracts):
❑ Yes ® No
The following applies if the answer to item above is "Yes" (Terminal Liability Option):
Must be elected at Policy inception or renewal. Premium cost is calculated by taking the average enrollment for
the last two months of the Current Policy Period multiplied by three times pre -termination Individual Stop Loss
rate(s). Premium is due at the time of termination, payable by lump sum within 10 days of receipt of bill. Claims
will accumulate and be combined under one Individual Stop Loss Deductible specified in item B.4.a above for the
Current Policy Period and Terminal Period. The Settlement for the Final Accounting Period will be described in the
section of the Policy entitled SETTLEMENTS.
6. Individual Stop Loss Premium
Monthly Individual Stop Loss Premium shall be equal to the amounts obtained by multiplying the
number of Covered Employees for a particular Month by:
$19.60 Composite; or
$ for each Single Coverage Unit
$ for each Family Coverage Unit
C. Aggregate Stop Loss Coverage: Yes ❑ No
If yes, complete Items 1. through 5. Below:
1. New Coverage ❑ Renewal of Existing Coverage ❑
2. Stop Loss Coverage during the current Policy Period
❑ Choose an item
Coverage for Claims incurred from to and Claims paid from to
If 24/12, 18/12, 15/12, or 12/12 are selected, Employer Group understands that run -out coverage is not included,
and Employer Group represents that it intends to purchase run-in coverage from its next carrier.
2
TX SL-APP Rev. 3.21
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company
an Independent Licensee of the Blue Cross and Blue Shield Association
For new coverage only, if a run-in contract as explained in the policy (24/12, 18/12, or 15/12 coverage period) is
purchased, claims paid by the Employer Group's prior claim administrator will be settled at the time of the annual
stop loss settlement and must be reported by the Employer Group to the Company (Blue Cross and Blue Shield of
Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company) by the end of the
Employer Group's Current Policy Period or stop loss coverage for these run-in claims will be forfeited.
❑ (Paid Renewal Only) Claim Administrators Claims: Claims incurred on or after the Original Effective Date of
Policy and paid during the Policy Period.
3. Covered Expenses:
❑ Medical Claims
❑ Claim Administrator's Provider Access Fees
❑ Prescription Drug Claims with: Choose an item
❑ For Hospital Employer Groups only: Excludes % of Home Hospital Medical claims
❑ Other (for example DentalMsion):
4. Aggregate Claim Liability
a. Attachment Factor % of the Average Claim Value
b. Aggregate Claim Factors:
Group Number:
Composite; or
$
$
$
$
For each Single Coverage Unit
$
$
$
$
For each Family Coverage Unit
A
$
$
$
c. Minimum Aggregate Point of Attachment: $
5. Terminal Liability Option (TLO) (does not apply to Employer Groups with 12/15, 12/18, or 12/24 contracts):
❑ Yes ❑ No
The following applies if the answer to item above is "Yes" (Terminal Liability Option):
Must be elected at Policy inception or renewal. Premium cost is calculated by taking the average enrollment for the
last two months multiplied by three times pre -termination Aggregate Stop Loss rate(s). Premium is due at the time
of termination, payable by lump sum within 10 days of receipt of bill.
The Final Settlement Point of Attachment shall equal the sum of the Employer's Aggregate Claim Liability amount
for the Policy Period plus 15% of the Aggregate Claim Factor multiplied by 12, and then multiplied by the average
enrollment for the last two (2) months of the Current Policy Period immediately preceding termination. Furthermore,
for the Final Settlement Period, the Minimum Aggregate Point of Attachment shall be the Minimum Aggregate Point
of Attachment in item CA.c. above increased by 15%. The Settlement for the Final Accounting Period will be
described in the section of the Policy entitled SETTLEMENTS.
6. Aggregate Stop Loss Premium:
❑ Monthly Premium
Monthly Aggregate Stop Loss Premium shall be equal to the amounts obtained by multiplying the number
of Covered Employees for a particular Month by:
$ Composite; or
$ for each Single Coverage Unit
$ for each Family Coverage Unit
3
TX SL-APP Rev. 3.21
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company
an Independent Licensee of the Blue Cross and Blue Shield Association
❑ Annual Premium (Due on the first day of the Current Policy Period): $
D. Additional Provisions (if elected):
1. Retirees Covered (select if included):
Pre-65: ® or Post-65:
2. Home Hospital Employer Groups Only: Home Hospital Provider Number(s) subject to exclusion percentage per
Item B.3. & C.3.:
3. Monthly Aggregate Accommodation: ❑ Yes ® No
4. Additional information: The Individual Stop Loss quote is being offered on a 12;15 basis during the policy period indicated
above.
5. Paid Claims subject to Individual Stop Loss are paid claims from the following line(s) of coverage: Medical and Drug
Fraud Notice: Any person who knowingly, with intent to injure, defraud or deceive any insurance company submits an
application containing any false, incomplete, or misleading information, may be subject to prosecution and may be found
guilty of a felony under state law and subject to punishment, including fines and/or imprisonment. Submission of false
information in connection with this application may also constitute a crime under federal laws. All appropriate legal remedies
will be pursued in the event of insurance fraud, including prosecution under Federal Mail or Wire Fraud statutes, and/ or the
Federal Racketeer Influenced and Corrupt Organizations Act. Any false statements made herein may be reported to state
and federal tax and regulatory authorities as is appropriate.
The undersigned person represents that he/she is authorized and responsible for purchasing Stop Loss Coverage on behalf
of the Employer Group. It is understood that the actual terms and conditions of coverage are those contained in this
Application and the Stop Loss Coverage Policy into which this ,Application shall be incorporated at the time of acceptance
by Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company
("HCSC"). Upon acceptance, HCSC shall issue a Stop Loss Coverage Policy to the Employer Group. Upon acceptance of
this Application and issuance of the Stop Loss Coverage Policy, the Employer Group shall be referred to as the
"Policyholder".
Taylor Holbrook ��"" ' V
Sales Representative 9/29/2022
Purchaser
Tray yne, Mayor
Tit of Authorized Purchaser
October 11, 2022
Date
CI
TX SL-APP Rev. 3.21
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company
an Independent Licensee of the Blue Cross and Blue Shield Association