RFP 01101 Addendum I

ADDENDUM I

DATE: Thursday, October 13, 2022

TO: ALL PROSPECTIVE OFFERORS

FROM: Angie Perteet Senior Buyer

RE: Addendum I, 01101 RFP Employee and Retiree Individual Stop-Loss Insurance

ACCG - Anthem Data for Stop Loss Marketing and Health Census for Stop Loss data is added to RFP # 01101 Employee and Retiree Individual Stop-Loss Insurance.

All other terms and conditions remain unchanged.

Inquiries regarding proposals should be made to Angie Perteet, Senior Buyer, (762) 400-6053, or accbids@accgov.com. Technical questions may be directed to Stephen McKenzie, Epic Brokers,

(678) 591-1222 or email stephen.mckenzie@epicbrokers.com, Laura Clark, Epic Brokers, (678) 650-3613 or email Laura.Clark@epicbrokers.com, Carrie Arnold, Epic Brokers, (770) 856-0308 or email: Carrie. Arnold@epicbrokers.com, Traci Mason, Human Resources Department (706) 613-3116 or email traci.mason@accgov.com.

The Unified Government of Athens-Clarke County reserves the right to reject any and all proposals, to waive any technicalities or irregularities and to award the offer based on the highest and best interest of The Unified Government Athens-Clarke County.

Attachments:

1. ACCG - Anthem Data for Stop Loss Marketing

2. Health Census for Stop Loss data

3. Administrative Services Agreement

4. Monthly Medical Rates

5. Stop Loss Policy mailto:accbids@athensclarkecounty.com mailto:stephen.mckenzie@epicbrokers.com tel:1-555-555-5555 mailto:Laura.Clark@epicbrokers.com mailto:Carrie.%20Arnold@epicbrokers.com

FROM: Angie Perteet

AMENDMENT 6 TO THE

ADMINISTRATIVE SERVICES AGREEMENT

WITH

ATHENS CLARKE COUNTY

This Amendment is made part of the Administrative Services Agreement and is effective January 1, 2021. This Amendment supplements and amends the Agreement between Employer and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. dba Anthem Blue Cross and Blue Shield dba Anthem. If there are any inconsistencies between the terms of the Agreement or its Schedules and this Amendment, the terms of this Amendment shall control.

1. SCHEDULE A is replaced by the attached SCHEDULE A.

2. SCHEDULE B is replaced by the attached SCHEDULE B.

3. SCHEDULE C is replaced by the attached SCHEDULE C.

4. EXHIBIT A OF THE PHARMACY BENEFITS ADMINISTRATIVE SERVICES SCHEDULE is replaced by the attached EXHIBIT A OF THE PHARMACY BENEFITS ADMINISTRATIVE SERVICES SCHEDULE.

5. EXHIBIT B OF THE PHARMACY BENEFITS ADMINISTRATIVE SERVICES SCHEDULE is replaced by the attached EXHIBIT B OF THE PHARMACY BENEFITS ADMINISTRATIVE SERVICES SCHEDULE.

6. EXHIBIT C OF THE PHARMACY BENEFITS ADMINISTRATIVE SERVICES SCHEDULE is replaced by the attached EXHIBIT C OF THE PHARMACY BENEFITS ADMINISTRATIVE SERVICES SCHEDULE.

IN WITNESS WHEREOF, Anthem has caused this Amendment to be executed by affixing the signature of its duly authorized officer.

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. dba Anthem Blue Cross and Blue Shield

By:

Bettina Gregg

Title:

Regional Vice President

Date:

March 17, 2021

SCHEDULE A

TO

ADMINISTRATIVE SERVICES AGREEMENT

WITH

Athens Clarke County

This Schedule A shall govern the Agreement Period from January 1, 2021 through December 31, 2021. For purposes of this Agreement Period, this Schedule shall supplement and amend the Agreement between the Parties. If there are any inconsistencies between the terms of the Agreement including any prior Schedules, and this Schedule A, the terms of this Schedule A shall control.

Section 1. Effective Date and Renewal Notice

This Agreement Period shall be from 12:01 a.m. January 1, 2021 to the end of the day of December 31, 2021.

Paid Claims shall be processed pursuant to the terms of this Agreement when incurred and paid as follows:

Incurred from July 1, 2010 through December 31, 2021 and

Paid from January 1, 2021 through December 31, 2021.

Anthem shall provide any offer to renew this Agreement at least 60 days prior to the end of an Agreement Period.

Section 2. Broker or Consultant Base Compensation

Not Applicable

Section 3. Administrative Services Fees

Change to Administrative Services Fees. In addition to the provisions in Article 18(c), Anthem reserves the right to change the Administrative Services Fees provided in this Section 3 of Schedule A during the Agreement Period based upon the occurrence of any of the following events:

· Employer's enrollment is not within +/-10% of 1,587 Subscribers;

· A change in law or regulation that materially impacts underwriting assumptions made at the time of the offer or renewal.

If Employer terminates the Pharmacy Services Schedule with PBM at any time, then Anthem shall have the right to amend the Administrative Services Fees indicated in Section 3 of Schedule A of this Agreement.

A. Base Administrative Services Fee

POS

Composite $33.49 per Subscriber per month

HSA

Composite $33.49 per Subscriber per month

Article 3(a) Retroactive Adjustments to Enrollment.

Anthem shall credit Administrative Services Fees for each retroactive deletion up to a maximum of 60 days and shall charge Administrative Services Fees for each retroactive addition up to a maximum of 60 days.

B. Health and Wellness Program Fees

Enhanced Clinical, Health and Wellness Foundational Packages Included in the Administrative Services Fee.

C. Other Fees or Credits

Fee for Subrogation Services. The charge to Employer is 25% of gross subrogation recovery.

Fee for Overpayment Identification and Claims Prepayment Analysis Activities. The charge to Employer is 25% of (i) the amount recovered from review of Claims and membership data and audits of Provider and Vendor activity to identify overpayments and (ii) the difference between the amount Employer would have been charged absent prepayment analysis activities and the amount that was charged to Employer following performance of the prepayment analysis activities. This includes, but is not limited to COB, contract compliance, and eligibility. The fee for Overpayment Identification and Claims Prepayment Analysis Activities will not exceed $25,000.00 per Claim.

Enhanced Personal Health Care Fee. A fee shall be charged for Anthem's oversight of Enhanced Personal Health Care with Providers or Vendors. Such fee shall be 25% of the per attributed Member per month amount charged to Employer for the Provider performance bonus portion of the Enhanced Personal Health Care program. These charges are included in Paid Claims on the invoice and may accumulate towards any stop loss policy amounts.

Capitation Fee. A capitation fee shall be charged for Anthem's oversight and care coordination of designated Members. Such fee shall be 20% of the capitated Provider payment. These charges are included in Paid Claims on the invoice and may accumulate towards any stop loss policy amounts.

Non-Network Savings Fee. If Anthem or its Vendor negotiates with a non-Network Provider for Covered Services from the non-Network Provider, Employer will pay a fee equal to 50% of the difference between the non-Network Provider's Billed Charges and the amount Anthem uses to calculate Plan liability for the Covered Service (the "Plan Liability Amount"). In the case of facility-based Provider Claims, Plan Liability Amount will be based on the negotiated rate; if negotiations are not successful, the Plan Liability Amount shall be determined using a pricing tool. In the case of professional Provider Claims, Plan Liability Amount will be based upon the negotiated rate obtained by Anthem or its Vendor, if applicable (in the absence of successfully negotiated Claims, there will be no fee charged as the amount will be determined by the local Blue plan). These Claims will not be included in any Performance Guarantee calculations.

Plan Program Credit. Anthem will provide a Plan Program Credit in the amount of $120,000.00. The Plan Program Credit is only available from January 01, 2021 through December 31, 2021 and, subject to Anthem approval, may be applied towards any combination of the following:

· Plan Communications

· Wellness Programs

· Implementation or Claims Audit

· Additional Reporting or Data Feeds

· and Other – such as Innovation or Technology.

The Plan Program Credit does not apply towards programming expenses that are not directly related to administration of health care benefits, personnel/general consultant expenses, travel, and cash incentives.

Flexible Spending Account (FSA) Administration and Optional Services. Comment by Sakacsi, Lana: The HSA fees are included in the admin and the FSA fee is $3.20 per account or $0.95 for a member that has an HSA and a limited purpose FSA.

All Inclusive FSA fee $0.95 per FSA Participant per month

Health Savings Account (HSA) Administration. $2.25 per HSA Participant per month

Section 4. Paid Claims, Billing Cycle and Payment Method

A. Paid Claims

Paid Claims are described in Article 1-Paid Claims Definition of the Agreement.

B. Billing Cycle

Weekly

Anthem shall notify Employer of the amount due to Anthem as a result of Claims processed and paid by Anthem according to the billing cycle described above. The actual date of notification of Paid Claims and the Invoice Due Date will be determined according to Anthem's regular business practices and systems capabilities.

C. Payment Method

ACH or Wire Transfer Reimbursement for Paid Claims. Employer shall deposit the amount due in a designated Anthem bank account by the Invoice Due Date. The deposit shall be made in accordance with any policies and regulations of the bank necessary to assure that the deposit is credited to Anthem's account no later than the next business day.

Section 5. Administrative Services Fees Billing Cycle and Payment Method

A. Billing Cycle

Self-Bill. The Invoice Due Date is the 1 day of each month and funds are due on that day.

B. Payment Method

ACH or Wire Transfer Reimbursement. Employer shall deposit the amount due in a designated Anthem bank account by the Invoice Due Date. The deposit shall be made in accordance with any policies and regulations of the bank necessary to assure that the deposit is credited to Anthem's account no later than the next business day.

Section 6. Claims Runout Services

A. Claims Runout Period

Claims Runout Period shall be for the 12 months following the date of termination of this Agreement.

B. Claims Runout Administrative Services Fee

Medical:

The fee for Claims Runout Services will be equal to 9% of Claims processed and paid by Anthem or through Inter-Plan Arrangements. Fees in Sections 3(B) and 3(C) of this Schedule A that (i) are associated with Claims processed or reviewed during the Claims Runout Period including without limitation subrogation fees, Claims prepayment analysis fees, recovery fees, network access fees; or (ii) apply to the Agreement Period but were not billed during the Agreement Period, will also be billed and payable during the Claims Runout Period. Payment is due to Anthem by the Invoice Due Date.

Section 7. Inter-Plan Arrangements

Certain fees and compensation are charged each time a Claim is processed through the BlueCard Program and include, but are not limited to, Access Fees, Administrative Expense Allowance Fees, Central Financial Agency Fees and ITS Transaction Fees. Other Inter-Plan Program related fees that Anthem may charge include, but are not limited to, fees for BlueCross Blue Shield Global Core® Program services. These fees may be separately billed or included in Paid Claims. The extent to which these fees and compensation are (i) included in the Base Administrative Services Fee; or (ii) included in Paid Claims or separately billed to Employer is as follows:

BlueCard Fees

Access Fees (Network Provider Claims only):

• 2.11% for 1,000–9,999 Blue PPO enrolled Subscribers of network savings, capped at $2,000.00 per Claim.

Central Financial Agency Fee ("CFA") (Network Provider, Non-Network Provider and Blue Cross Blue Shield Global Core Claims):

• $0.35 per payment notice.

ITS Transaction Fee ("ITS") (Network Provider, Non-Network Provider and Blue Cross Blue Shield Global Core Program Claims):

• $0.05 per transaction.

Negotiated Arrangement Fees - Not Applicable

Blue Cross Blue Shield Global Core Fees

Administrative Expense Allowance Fee:

• $3.75 per Member-submitted Claim;

• $4.75 per professional Claim; and

• $17.00 per institutional Claim.

All other fees associated with the Blue Cross Blue Shield Global Core program, except the CFA and ITS Fees described above, are included in the Base Administrative Services Fee.

Section 8. Other Amendments. The Administrative Services Agreement is otherwise amended as follows:

Notice of Loss of Grandfathering Status

In the event Employer maintains a grandfathered health plan(s), as that term is used in the Patient Protection and Affordable Care Act ("PPACA"), Employer shall not make any changes to such plan(s), including, but not limited to, changes with respect to Employer contribution levels, without providing Anthem with advance written notice of the intent to change such plan(s). Making changes to grandfathered plans without notice to Anthem may result in the plan(s) losing grandfathered status and significant penalties and/or fines to Employer and Anthem. In the event Employer implements changes to its plan(s) and does not provide advance notice to Anthem, Employer agrees to indemnify Anthem according to the indemnification provisions set forth elsewhere in this Agreement for any penalties, fines or other costs assessed against Anthem.

Additionally, at each renewal after September 23, 2010, Employer shall affirm in writing, upon reasonable request of Anthem, that it has not made changes to its plan(s) that would cause the plan(s) to lose its/their grandfathered status.

If Employer loses grandfathered Plan status under PPACA and notifies Anthem of such loss no fewer than 90 days before the effective date of the change, Anthem will implement the additional group market (insurance) reforms that apply to non-grandfathered health Plans subject to the provisions of Article 18 of this Agreement.

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. dba Anthem Blue Cross and Blue Shield

By:

Bettina Gregg

Title:

Regional Vice President

Date:

March 17, 2021

SCHEDULE B

TO

ADMINISTRATIVE SERVICES AGREEMENT

WITH

ATHENS CLARKE COUNTY

This Schedule B shall govern the Agreement Period from January 1, 2021 through December 31, 2021. For purposes of this Agreement Period, this Schedule B shall supplement and amend the Agreement between the Parties. If there are any inconsistencies between the terms of the Agreement including any prior Schedules and this Schedule B, the terms of this Schedule B shall control.

The following is a list of services that Anthem will provide under this Agreement for the Base Administrative Services Fee listed in Section 3(A) of Schedule A. These services will be furnished to Employer in a manner consistent with Anthem's standard policies and procedures for self-funded plans.

Anthem may also offer additional, optional services to Employer, and such services, whether or not purchased by Employer, are not included in the services set forth below in this Schedule B. By way of example and not limitation, Anthem may offer certain optional programs that include utilization management activities. In such event, the services associated with those programs are not included in the services described below. Services under Article 13 will only be pursued or performed for Claims associated with these programs or that would have been impacted by these programs if the programs are purchased by Employer. If Employer has purchased such services, those services and any additional fees are also listed in Schedule A.

SERVICES INCLUDED IN THE BASE ADMINISTRATIVE SERVICES FEE IN SECTION 3A OF SCHEDULE A

Management Services:

Anthem's benefits and administration as described in this paragraph:

· Anthem definitions, and exclusions

· Anthem complaint and appeals process (One mandatory level of appeal, one voluntary level of appeal)

· Claims incurred and paid as provided in Schedule A, excluding activities related to Claim recovery

· Accumulation toward plan maximums beginning at zero on effective date

· Anthem Claim forms

· ID card

· Explanation of Benefits (Non-customized)

• Acceptance of electronic submission of eligibility information in HIPAA-compliant format

• Preparation of Benefits Booklet (accessible via internet)

• Information for ERISA 5500

• Account reporting - standard data reports

• Standard billing and banking services

• Plan Design consultation

• Employer eServices

- Add and delete Members

- Download administrative forms

- View Member Benefits and request ID cards

- View eligibility

- View Claim status and detail

• Responsible Reporting Entity for the Plan

• Information for preparation of SBC

Claims and Customer Services

• Claims processing services

• Medicare crossover processing

• Employer customer service, standard business hours

• Member customer service, standard business hours

• 1099s prepared and delivered to Providers

• Residency-based assessments and/or surcharges and other legislative reporting requirements

• Member eServices

• Member identity theft and credit monitoring and identity repair

Care Management

• Health Care Management

- Referrals

- Utilization management

- Case management

- Anthem Medical Policy

• SpecialOffers

• Transplant services - Blues Distinction

• Member Digital Tools

Networks

• Network Access and Management

• Online Provider directory

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. dba Anthem Blue Cross and Blue Shield

By:

Bettina Gregg

Title:

Regional Vice President

Date:

March 17, 2021

SCHEDULE C

TO THE

ADMINISTRATIVE SERVICES AGREEMENT

WITH

ATHENS CLARKE COUNTY

This Schedule C provides certain guarantees pertaining to Anthem's performance under the Agreement between the Parties ("Performance Guarantees") and shall be effective for the period from January 1, 2021 through December 31, 2021 (the "Performance Period"). Descriptions of the terms of each Performance Guarantee applicable to the Parties are set forth in the Attachments (the "Attachments") to this Schedule C and made a part of this Schedule C. This Schedule shall supplement and amend the Agreement between the Parties. If there are any inconsistencies between the terms of the Agreement including any prior Schedules and this Schedule C, the terms of this Schedule C shall control. If there are any inconsistencies between the terms contained in this Schedule, and the terms contained in any of the Attachments to this Schedule C, the terms of the Attachments to this Schedule C shall control unless otherwise specified .

Section 1. General Conditions

A. The Performance Guarantees described in the Attachments to this Schedule C shall be in effect only for the Performance Period indicated above, unless specifically indicated otherwise in the Attachments. Each Performance Guarantee shall specify a/an:

1. Performance Category. The term Performance Category describes the general type of Performance Guarantee.

2. Reporting Period. The term Reporting Period refers to how often Anthem will report on its performance under a Performance Guarantee.

3. Measurement Period. The term Measurement Period is the period of time under which Anthem's performance is measured, which may be the same as or differ from the period of time equal to the Performance Period.

4. Penalty Calculation. The term Penalty Calculation generally refers to how Anthem's payment will be calculated, in the event Anthem does not meet the target(s) specified under the Performance Guarantee.

5. Amount at Risk. The term Amount at Risk means the amount Anthem may pay if it fails to meet the target(s) specified under the Performance Guarantee.

B. Anthem shall conduct an analysis of the data necessary to calculate any one of the Performance Guarantees within the timeframes provided in the Attachments to this Schedule C. In addition, any calculation of Performance Guarantees, reports provided, or analysis performed by Anthem shall be based on Anthem's then current measurement and calculation methodology, which shall be available to Employer upon request.

C. Any audits performed by Anthem to test compliance with any of the Performance Guarantees shall be based on a statistically valid sample size with a 95% confidence level.

D. If the Parties do not have an executed Agreement, Anthem shall have no obligation to make payment under these Performance Guarantees.

E. Unless otherwise specified in the Attachments to this Schedule C, the measurement of the Performance Guarantee shall be based on data that is maintained and stored by Anthem or its Vendors.

F. If Employer terminates the Agreement between the Parties prior to the end of the Performance Period, or if the Agreement is terminated for non-payment, then Employer shall forfeit any right to collect any further payments under any outstanding Performance Guarantees, whether such Performance Guarantees are for a prior or current Measurement Period or Performance Period.

G. Anthem reserves the right to make changes to any of the Performance Guarantees provided in the Attachments to this Schedule C upon the occurrence, in Anthem's determination, of:

1. a change to the Plan benefits or the administration of the Plan initiated by Employer that results in a substantial change in the services to be performed by Anthem or the measurement of a Performance Guarantee;

2. an increase or decrease of 10% or more of the number of Members that were enrolled for coverage on the latter of the effective date or renewal date of this Agreement;

3. a change in law or regulation that materially impacts underwriting assumptions made at the time of offering such Performance Guarantees.

H. For the purposes of calculating compliance with the Performance Guarantees contained in the Attachments to this Schedule C, if a delay in performance of, or inability to perform, a service underlying any of the Performance Guarantees is due to circumstances which are beyond the control of Anthem, or its Vendors, including but not limited to any act of God, civil riot, floods, fire, acts of terrorists, acts of war or power outage, such delayed or non-performed service will not count towards the measurement of the applicable Performance Guarantee.

I. Some Performance Guarantees measure and compare year to year performance. Other than as set forth below, the term Baseline Period refers to the equivalent time period preceding the Measurement Period. Notwithstanding anything to the contrary in the Agreement, this Schedule C, or any Attachment to this Schedule C, the Baseline Period for the Performance Period year that begins in 2021 for any Care Management / Health and Wellness Performance Guarantee shall be the time period occurring from January 1, 2019 through December 31, 2019. Anthem will require specified historical Claims and utilization data to establish the Baseline Period for the first year of a Performance Guarantee utilizing a Baseline Period.

J. As determined by Anthem, Performance Guarantees may be measured using either aggregated data or Employer-specific Data. The term Employer-specific Data means the data associated with Employer's Plan that has not been aggregated with other employer data. Performance Guarantees will specify if Employer-specific Data shall be used for purposes of measuring performance under the Performance Guarantee.

K. If any Performance Guarantees are tied to a particular program and its components, such Performance Guarantees are only valid if the Employer participates in the program and its components for the entirety of the Measurement Period associated with the Performance Guarantee.

L. All Performance Guarantees in which Anthem will make outbound calls or will reach out through email or other means to members will exclude members who Anthem cannot reach due to incorrect or invalid telephone numbers, including numbers where permission is required by law but not provided, or those members who have requested that Anthem not contact them.

M. All Performance Guarantees may be revisited and may potentially be impacted due to a cause beyond the reasonable control of a Party such as a pandemic (an outbreak of disease that affects an exceptionally high proportion of members) being declared by the Centers for Disease Control or if a Force Majeure event (meaning an act of God, civil or military disruption, terrorism, fire, strike, flood, riot or war) occurs during the Measurement or Baseline Period that impacts a meaningful portion of the Employer population.

Section 2. Payment

A. If Anthem fails to meet any of the obligations specifically described in a Performance Guarantee, Anthem shall pay Employer the amount set forth in the Attachment described under the Performance Guarantee. Payment shall be in the form of a credit on Employer's invoice for Administrative Services Fees, which will occur annually unless otherwise stated in the Performance Guarantee.

B. Notwithstanding the above, Anthem has the right to offset any amounts owed to Employer under any of the Performance Guarantees contained in the Attachments to this Schedule C against any amounts owed by Employer to Anthem under: (1) any Performance Guarantees contained in the Attachments to this Schedule C; (2) the Agreement; or, (3) any applicable Stop Loss Policy.

C. Notwithstanding the foregoing, Anthem's obligation to make payment under the Performance Guarantees is conditioned upon Employer's timely performance of its obligations provided in the Agreement in this Schedule C, and the Attachments, including providing Anthem with the information or data required by Anthem in the Attachments. Anthem shall not be obligated to make payment under a Performance Guarantee if Employer or Employer's vendor's action or inaction adversely impacts Anthem's ability to meet any of its obligations provided in the Attachments related to such Performance Guarantee, which expressly includes but is not limited to Employer or its vendor's failure to timely provide Anthem with accurate and complete data or information in the form and format expressly required by Anthem.

D. Where the Amount at Risk for a Performance Guarantee is on a percentage of a Per Subscriber Per Month (PSPM) fee basis, the Guarantee will be calculated by multiplying the PSPM amount by the actual annual enrollment during the Measurement Period.

Section 3. Performance Guarantee Amounts at Risk

Amount at Risk

The total amount at risk for the below performance guarantees between Anthem and Athens-Clarke County shall not exceed the following:

Operations Guarantees: 15% of Base Medical Administration fees of $22.35 PEPM Comment by Sakacsi, Lana: In year 1 it was 15%. In year 2 and 3, it is 13%.

Confirmation of all applicable fees for the performance guarantees will be reflected in Employer’s Schedule C.

Maximum Amount Payable

The maximum amount payable under all guarantees between Anthem and Athens-Clarke County shall not exceed 30% of the Base Medical Administration fees . The Maximum Amount Payable provisions above do not apply to Pharmacy-related Performance Guarantees. Pharmacy-related Performance Guarantees will be provided separately and will be specific to Pharmacy only.

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. dba Anthem Blue Cross and Blue Shield

By:

Bettina Gregg

Title:

Regional Vice President

Date:

March 17, 2021

ATTACHMENT 1 TO SCHEDULE C

Performance Guarantees

TO ADMINISTRATIVE SERVICES AGREEMENT

WITH

ATHENS CLARKE COUNTY

Operations Performance Guarantees

This Attachment is made part of Schedule C and will be effective for the Performance Period from January 1, 2021 through December 31, 2021. This Attachment is intended to supplement and amend the Agreement between the Parties.

Additional Terms and Conditions:

For purposes of imposing penalties, measurement shall not begin until the start of the fourth month of the initial Agreement period for the following measures: Claims Timeliness, Claims Financial Accuracy, Claims Accuracy, Average Speed of Answer, Call Abandonment Rate, and First Call Resolution.

Performance will be based on the results of a designated service team/business unit assigned to Athens-Clarke County, unless the guarantee is noted as measured with Employer-specific Data.

Performance Category

Amount at Risk

Guarantee

Penalty Calculation

Measurement and Reporting Period

Implementation

Year 1:

2% of Base Admin. Services Fees

A minimum of 95% of all tasks will be completed by the dates specified in the implementation plan agreed to by the Parties.

The implementation plan will be developed by Anthem and will contain tasks to be completed by Employer and/or Anthem and a timeframe for completion of each task. The implementation plan will also contain Measurement Periods specific to each task. Anthem’s payment under this Guarantee is conditioned upon Employer’s completion of all designated tasks by the dates specified in the implementation plan.

This will be measured with Employer-specific Data.

Result

Penalty

95.0% or Greater

None

91.0% to 94.9%

25%

89.0% to 90.9%

50%

85.0% to 88.9%

75%

Less than 85.0%

100%

Measurement Period

Defined in Implementation Plan

Reporting Period

60 calendar days following the end of the implementation period

Implementation Survey

Year 1:

2% of Base Admin. Services Fees

A minimum average score of 3.0 will be attained on the Implementation Survey.

Anthem will prepare and send an Implementation Survey to Employer. Anthem will only consider survey results received within 30 calendar days from the delivery of the survey to the Employer.

Average Number of Points

Penalty

3.0 or Greater

None

2.6 to 2.9

25%

2.3 to 2.5

50%

2.0 to 2.2

75%

Less than 2.0

100%

Measurement Period

Annual

60 days following Anthem’s receipt of the Survey

Claim Timeliness (30 Calendar Days)

Year 1:

1% of Base Admin. Services Fees

Year 2, 3:

A minimum of 98% of Non-investigated medical Claims will be processed timely.

Non-investigated medical Claims are defined as Claims that process through the system without the need to obtain additional information from the Provider, Subscriber, or other external sources. Processed Timely is defined as Non-investigated medical Claims that have been adjudicated within 30 calendar days of receipt.

This Guarantee will be calculated based on the number of Non-investigated Claims that Processed Timely divided by the total number of Non-investigated Claims.

The calculation of this Guarantee does not include Claim adjustments. The calculation of this Guarantee also excludes in any quarter, Claims for an Employer that requests changes to Plan benefits, until all such changes have been implemented.

This will be measured with Employer-specific Data.

Result

Penalty

98.0% or Greater

None

96.0% to 97.9%

25%

94.0% to 95.9%

50%

92.0% to 93.9%

75%

Less than 92.0%

100%

Measurement Period

Claims Financial Accuracy

Year 1:

A minimum of 99% of medical Claim dollars will be processed accurately.

This Guarantee will be calculated based on the total dollar amount of audited medical Claims paid correctly divided by the total dollar amount of audited medical Paid Claims. The calculation of this Guarantee includes both underpayments and overpayments. The calculation of this Guarantee does not include Claim adjustments or Claims in any quarter in which an Employer requests changes to Plan benefits, until all such changes have been implemented.

Result

Penalty

99.0% or Greater

None

98.0% to 98.9%

25%

97.0% to 97.9%

50%

96.0% to 96.9%

75%

Less than 96.0%

100%

Measurement Period

Claims Accuracy

Year 1:

A minimum of 97% of medical Claims will be paid or denied correctly.

This Guarantee will be calculated based on the number of audited medical Claims paid and denied correctly divided by the total number of audited medical Claims paid and denied. The calculation of this Guarantee excludes in any quarter Claims for an Employer that requests changes to Plan benefits, until all such changes have been implemented.

Result

Penalty

97.0% or Greater

None

96.0% to 96.9%

25%

95.0% to 95.9%

50%

94.0% to 94.9%

75%

Less than 94.0%

100%

Measurement Period

Open Enrollment ID Card Issuance

Year 1:

100% of Subscriber digital ID cards will be available or Member physical ID cards will be mailed to Open Enrollment participants no later than the Employer’s effective date provided that Anthem receives an Accurate Eligibility File. An Accurate Eligibility File is defined as: (1) an electronic eligibility file formatted in a mutually agreed upon manner; (2) received by Anthem no later than 30 calendar days prior to the Employer’s effective date; and, (3) contains an error rate of less than 1%. This Guarantee will be calculated based on the total number of Open Enrollment ID cards available to Subscribers or mailed to Members within the timeframe set forth above divided by the total number of Members eligible to receive Open Enrollment ID cards.

This Guarantee does not include digital cards for Anthem Dental services.

Result

Penalty

100%

None

99.0% to 99.9%

$100 per ID Card not to exceed 25% of amount at risk for this measure

98.0% to 98.9%

50%

97.0% to 97.9%

75%

Less than 97.0%

100%

Measurement Period

Employer’s effective date

60 days following the Employer’s effective date.

Processing of Ongoing Eligibility Information

Year 1:

100% of Employer’s ongoing electronic eligibility files will be processed timely.

Timely Processing is defined as electronic eligibility files processed and updated on the eligibility database within 7 business days of receipt of an eligibility file. This Guarantee only applies to the processing of eligibility files submitted by Employer outside of an open enrollment period. This Guarantee does not apply to a defective eligibility file. A defective Eligibility File is defined as an eligibility file that has issues that prevent Anthem’s processing of the file. Anthem’s payment of this Guarantee is conditioned upon receipt of eligibility files in a format mutually agreed upon by the Parties.

This Guarantee will be calculated by (1) dividing the total number of eligibility files processed within the timeframe set forth above by (2) the number of Employer’s eligibility files processed.

Result

Penalty

100%

None

98.0% to 99.9%

25%

96.0% to 97.9%

50%

94.0% to 95.9%

75%

Less than 94.0%

100%

Measurement Period

Ongoing ID Cards Issuance

Year 1:

A minimum of 99% of Subscriber digital ID cards will be available or Member physical ID cards will be mailed to Members within 10 business days of [Anthem’s] processing of an Accurate Eligibility File. An Accurate Eligibility File is defined as: (1) an eligibility file formatted in a mutually agreed upon manner; (2) received by Anthem outside of an open enrollment period; and, (3) contains an error rate of less than 1%. This Guarantee will be calculated based on the total number of ongoing ID cards available to Subscribers or mailed to Members within the timeframe set forth above divided by the total number of Members eligible to receive ongoing ID cards.

This Guarantee does not include digital cards for Anthem Dental services.

Result

Penalty

99.0% or Greater

None

98.0% to 98.9%

25%

97. 0% to 97.9%

50%

96.0% to 96.9%

75%

Less than 96.0%

100%

Measurement Period

Average Speed to Answer

Year 1:

The average speed to answer (ASA) will be 45 seconds or less.

ASA is defined as the average number of whole seconds members wait and/or are in the telephone system before receiving a response from a customer service representative (CSR) or an interactive voice response (IVR) unit. This Guarantee will be calculated based on the total number of calls received in the customer service telephone system.

Result

Penalty

45 seconds or less

None

46 to 48 seconds

25%

49 to 51 seconds

50%

52 to 54 seconds

75%

55 or more seconds

100%

Measurement Period

Call Abandonment Rate

Year 1:

A maximum of 5.0% of member calls will be abandoned.

Abandoned Calls are defined as member calls that are waiting for a customer service representative (CSR), but are abandoned before connecting with a CSR. This Guarantee will be calculated based on the number of calls abandoned divided by the total number of calls received in the customer service telephone system. Calls that are abandoned in less than 5 seconds will not be included in this calculation.

Result

Penalty

5.0% or Less

None

5.01% to 5.40%

25%

5.41% to 5.70%

50%

5.71% to 5.99%

75%

6.0% or Greater

100%

Measurement Period

First Call Resolution

Year 1:

A minimum of 85% of member calls will be resolved during the initial contact with no further follow up required.

First Call Resolution is defined as member callers receiving a response to their inquiry during an initial contact with no further follow-up required. This Guarantee will be calculated based on the total number of members who receive a First Call Resolution divided by the total number of calls received into the customer service telephone system.

Result

Penalty

85.0% or Greater

None

83.0% to 84.9%

25%

81.5% to 82.9%

50%

80.0% to 81.4%

75%

Less than 80.0%

100%

Measurement Period

Account Management Satisfaction

Year 1:

3% of Base Admin. Services Fees

3% of Base Admin. Services Fees

A minimum average score of 3.0 will be attained on the Account Management Satisfaction Survey (AMSS).

A minimum of 3 responses per Employer to the AMSS is required to base the score on Employer-specific responses only. If 3 responses are received from the Employer, an average score is calculated by adding the scores from each respondent divided by the total number of Employer respondents. If fewer than 3 responses are received, the score will be calculated as follows:

2 Employer responses: 2/3 of the score will be based on Employer-specific AMSS results and 1/3 of the score will be based on the aggregate score of all AMSS results received by the Account Management Team.

1 Employer- response: 1/3 of the score will be based on Employer- specific AMSS results and 2/3 of the score will be based on the aggregate score of all AMSS results received by the Account Management Team.

0 Employer responses: The score will be based on the aggregate score of all AMSS results received by the Account Management Team.

Result

Penalty

3.0 or higher

None

2.5 to 2.9

25%

2.0 to 2.4

50%

Less than 2.0

100%

Measurement Period

EXHIBIT A – FEES & EXPENSES

OF THE PHARMACY BENEFITS ADMINISTRATIVE SERVICES SCHEDULE

TO

ADMINISTRATIVE SERVICES AGREEMENT

WITH

Athens Clarke County

This Exhibit A shall govern the Agreement Period from 1/1/2021 through 12/31/2021 and is made part of this Pharmacy Benefits Administrative Services Schedule. This Exhibit is intended to supplement the Agreement between the Parties as it relates to Pharmacy Services only. In the event of an inconsistency between the applicable provisions of this Pharmacy Services Schedule and the Agreement, the terms of this Pharmacy Services Schedule shall govern, but only as they relate to Pharmacy Services. Except as set forth herein, all other terms and conditions of the Agreement remain in full force and effect.

Section 1. Effective Date and Renewal Notice

This Agreement Period shall be from 12:01 a.m. 1/1/2021 to the end of the day of 12/31/2021.

Paid Claims shall be processed pursuant to the terms of this Pharmacy Services Schedule when incurred and paid as follows:

· Paid from 1/1/2021 through 12/31/2021.

Section 2. Broker or Consultant Base Compensation

Not Applicable

Section 3. Pharmacy Administrative Services Fees

Change to Administrative Services Fees. The Administrative Services Fees in Section 3 of Schedule A of the Agreement and the Pharmacy Administrative Services Fees in Section 3 of Exhibit A may be changed during the Agreement Period based upon an event in Article 18(c) of the Agreement or Section E(2) of the Pharmacy Services Schedule.

1. Pharmacy Base Administrative Services Fee

Pharmacy Base Administrative Services Fee. The Pharmacy Administrative Services Fees shall also include a fee that will be charged monthly for services related to pharmacy benefits management including, but not limited to, pharmacy mail services, clinical services, and customer services. Such fee shall be:

$0.00

1. Drug Rebate Allocation

1. PBM and/or its Vendor has negotiated programs with pharmaceutical manufacturers for drug rebates on certain Prescription Drugs dispensed to Members and has arranged for payments of such rebates to be made directly to PBM (“Drug Rebate Programs”). PBM has entered into such Drug Rebate Programs on its behalf and not on behalf of Employer, and therefore retains all rights, title, and interest to any and all actual Prescription Drug Rebates it receives from manufacturers and/or its Vendor. Such Drug Rebate Programs are not based solely on the Prescription Drug utilization of one Employer Plan, but rather are based on the Prescription Drug utilization of all individuals enrolled in PBM managed programs. The Prescription Drug Rebates are conditioned on certain Prescription Drugs being included on the Formulary that PBM requires Employer to adopt as part of its Plan. Employer shall be paid or credited a portion or the amount attributable to its actual or estimated value of Prescription Drug Rebates as described in Section 3(B) of Exhibit A.

1. PBM may receive and retain Manufacturer Administrative Fees directly from pharmaceutical manufacturers. In addition, PBM may receive and retain service fees from pharmaceutical manufacturers for providing services (e.g., Provider and Member education programs that promote clinically appropriate and safe dispensing and use of Prescription Drugs). For purposes of this Pharmacy Services Schedule, Manufacturer Administrative Fees and service fees received by PBM shall not be considered Prescription Drug Rebates.

Prescription Drug Rebates: PBM will pay to Employer 100% of the Prescription Drug Rebates attributable to Employer’s Plan subject to PBM’s timely and actual receipt of payment and accompanying data from pharmaceutical manufacturers. On a Quarterly basis, PBM shall credit Employer the Prescription Drug Rebates it has collected. PBM shall have the right to collect from Employer any rebate amount that PBM is required to pay a pharmaceutical manufacturer as a result of a pharmaceutical manufacturer audit or for any other reason. Provided, however, if the total Prescription Drug Rebates Performance Guarantee, as defined in Exhibit C, exceeds the amount described herein, the PBM will pay the Employer the difference.

Medical Drug Rebates. PBM shall pay to Employer 50.00% (YR1) 75.00% (YR2) of the Medical Drug Rebates attributable to Employer’s Plan subject to PBM’s timely and actual receipt of payment and accompanying data from pharmaceutical manufacturers subject to any deduction for shared savings under Section 3(C) of this Exhibit A. The actual rebate amount will be determined by reconciling the Medical Drug Rebate amount payable against shared savings on a annual basis.

1. Other Fees or Credits

Fee for Pharmacy Prior Authorization $55.00 per authorization.

Fee for Step Therapy PBM shall charge a fee of $0.30 per pharmacy Claim.

Fee for Quantity Limits PBM shall charge a fee of $0.55 per pharmacy Claim for applying frequency and quantity limits to certain Prescription Drugs.

Fee for Pharmacy Physician Review $800.00 per review.

Fee for Vaccine Administration PBM shall charge a fee for the administration of vaccines at a retail pharmacy location of $2.50 per vaccine.

Fee for Custom Communications PBM shall charge a fee of $1.00 per custom communication requested by the Employer.

Fee for Member-Submitted Claims PBM shall charge a fee of $1.00 per Claim for each Member-submitted Claim.

Fee for Core Optimization Program PBM shall charge a fee of $0.25 per pharmacy Claim for clinical, quality and cost of care messages in personalized Member communications.

Fee for Specialty Cost Optimization The charge to Employer for administration and management of the Specialty Cost Optimization Program is 50% of the shared savings attained through PBM’s Specialty Cost Optimization Program capped at $0.50 PMPM. PBM’s shared savings fee shall be deducted from the Medical Drug Rebate due Employer. In no event will PBM charge Employer a shared savings fee if the Medical Drug Rebate due to the Employer is less than the shared savings fee due to PBM.

PBM Services Early Termination Fee In consideration of the special pricing arrangements under this Agreement, Employer shall pay PBM an Early Termination Fee, as described below, if Employer terminates the pharmacy portion of the Plan before the end of the Performance Period (as defined in Exhibit C) for any reason other than PBM’s failure to comply with a material duty or obligation related to the administration of pharmacy benefits under this Agreement.

The Early Termination Fee shall be calculated by multiplying $3.00 PSPM by (i) the average monthly Subscriber count for the 6 months immediately prior to termination; multiplied by (ii) the number of months remaining in the Performance Period. Upon termination of the Agreement, 0.00% of unpaid Rebates for services prior to termination will be retained by PBM subject to the provisions of Article 7. If Employer intends to terminate the pharmacy portion of the Plan before the end of the Performance Period, Employer must provide PBM with the required termination notice under Section G of the Pharmacy Services Schedule. In the event Employer terminates the pharmacy portion of the Plan before the end of the Performance Period, the applicable Early Termination Fee will be billed to Employer with the amount due within 30 days of the termination date.

Invoices for Prescription Drug Claims.

When PBM invoices Employer for Prescription Drug Claims, the amount billed will reflect pricing that may be greater than the amount that is paid to pharmacies for those Claims (Margin Pricing). The use of Margin Pricing provides some control over price swings that Members may otherwise experience when filling prescriptions.

Fee for Ad Hoc Reports. PBM shall provide, on an annual basis, up to 20 hours of time needed to generate custom or ad hoc reports at no additional charge. The charge to Employer beyond 20 hours per year is $150.00 per hour for time needed to generate custom or ad hoc reports.

Section 4. Pharmacy Administrative Services Fees and Paid Claims Billing Cycle and Payment Method

Billing cycles and payment methods are contained in Schedule A.

Section 5. Claims Runout Services

1. Claims Runout Period

Claims Runout Period shall be for the 12 months following the date of termination of this Pharmacy Services Schedule.

1. Claims Runout Administrative Services Fee

Pharmacy:

The fee for Claims Runout Services will be waived. Fees in Section 3(C) of this Exhibit A that (i) are associated with Claims processed or reviewed during the Claims Runout Period including without limitation subrogation fees, Claims prepayment analysis fees, recovery fees, network access fees; or (ii) apply to the Pharmacy Services Schedule Period but were not billed during the Pharmacy Services Schedule Period, will be billed and payable during the Claims Runout Period. Payment is due to PBM by the Invoice Due Date.

IN WITNESS WHEREOF, the Parties have executed this Exhibit to be effective as of the pharmacy Agreement Period.

Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. dba Anthem Blue Cross and Blue Shield

By:

Bettina Gregg

Title:

Regional Vice President

Date:

March 17, 2021

IngenioRx, Inc.

By: ______________________

Name: Nancy Gilbride

Title: VP & Chief Sales Officer - IngenioRx, IngenioRx President

Date: March 17, 2021

EXHIBIT B – PHARMACY SERVICES

TO THE

ADMINISTRATIVE SERVICES AGREEMENT

This Exhibit B shall govern the Agreement Period from 1/1/2021 through 12/31/2021 and is made part of this Pharmacy Benefits Administrative Services Schedule. This Exhibit is intended to supplement the Agreement between the Parties as it relates to Pharmacy Services only. In the event of an inconsistency between the applicable provisions of this Pharmacy Services Schedule and the Agreement, the terms of this Pharmacy Services Schedule shall govern, but only as they relate to Pharmacy Services. Except as set forth herein, all other terms and conditions of the Agreement remain in full force and effect.

The following is a list of standard services that PBM will provide under this Pharmacy Services Schedule for the Pharmacy Administrative Services Fees set forth on Section 3 of Exhibit A. These services will be furnished to Employer in a manner consistent with PBM’s standard policies and procedures for self-funded plans. PBM may also offer services to Employer that have an additional fee. If Employer has purchased such services, those services and any additional fees are also set forth on Exhibit A.

Prescription Benefit Services

· Home delivery pharmacy

· Specialty Pharmacy Services

· Prescription eServices

· Pharmacy locator

· Online Formulary

· Point of sale Claims processing (not including pharmacy COB services with are subject to additional fees)

· Home delivery Claims processing

· Home delivery call center with toll free number

· Home delivery regular shipping and handling

· Standard management reports

· Ad hoc reports up to 20 hours (subject to additional programming charge)

· Concurrent Drug Utilization Review (DUR) programs

· Retrospective DURs

· Administrative override (i.e., vacation, lost, stolen or spilled medications)

· Pharmacy help desk with toll free number

· Daily Claims review audits of Network Pharmacies

· Assistance in determining “creditable prescription drug coverage” under Medicare Part D

EXHIBIT C - PERFORMANCE GUARANTEES

TO THE

ADMINISTRATIVE SERVICES AGREEMENT

This Exhibit C provides certain guarantees pertaining to PBM’s performance under the Agreement between the Parties (“Performance Guarantees”) and shall be effective for each year in the period from 1/1/2021 through 12/31/2022 (the “Performance Period”). Descriptions of the terms of each Performance Guarantee applicable to the Parties are set forth in the Attachments (the “Attachments”) to this Exhibit C and made a part of this Exhibit C. This Exhibit shall supplement and amend the Pharmacy Benefits Administrative Services Schedule between the Parties. If there are any inconsistencies between the terms of the Agreement and this Exhibit C, the terms of this Exhibit C shall control.