BCBS CY 2027 Amendment

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
City Clerk Document No.
City Council Meeting Date: October 15, 2026
AMENDMENT TO CITY OF CHANDLER AGREEMENT
GROUP MEDICAL AND PHARMACY PROGRAM ADMINISTRATION
CITY OF CHANDLER AGREEMENT NO. HR2-948-4453
THIS AMENDMENT NO. 3 (Amendment No. 3) is made and entered into by and between the City of
Chandler, an Arizona municipal corporation (City), and Blue Cross Blue Shield of Arizona, an Arizona
non-profit corporation and an independent licensee of the Blue Cross Blue Shield Association
(Contractor), (City and Contractor may individually be referred to as Party and collectively referred to
as Parties) and made , 2026 (Effective Date).
RECITALS
WHEREAS, the Parties entered into an agreement on October 31, 2022, for group medical and pharmacy
program administration (Agreement); and
WHEREAS, the initial term of the Agreement was January 1, 2023, through December 31, 2024, with the
option of up to three two-year extensions; and
WHEREAS, the Parties through Amendment No. 1 exercised the first option to extend the Agreement
for two years through December 31, 2026; and
WHEREAS, the Parties through Amendment No. 2 amended the Agreement to replace the
Administrative Services Agreement Amendment for 2025 with the amended Administrative Services
Agreement Amendment for 2026; and
WHEREAS, the Parties through this Amendment No. 3 wish to amend the Agreement to exercise the
second option to extend the Agreement for two years from January 1, 2027, through December 31,
2028; and
WHEREAS, the Parties wish to amend the Agreement to replace the Administrative Services Agreement
Amendment for 2026 with the Administrative Services Agreement Amendment for January 1, 2027,
through December 31, 2027, and to update the Administrative Summary.
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Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
AGREEMENT
NOW THEREFORE, the Parties agree as follows:
1. The recitals are accurate and are incorporated and made a part of the Agreement by this
reference.
2. The term of the Agreement is hereby extended for two years from January 1, 2027, through
December 31, 2028.
3. Exhibit F of the Agreement, the Administrative Services Agreement Amendment for January 1,
2026, through December 31, 2026, is replaced by the Administrative Services Agreement
Amendment effective January 1, 2027, through December 31, 2027, including all associated
documents which are attached hereto as Exhibit A and made a part of this Amendment No. 3.
4. The Administrative Summary of the Agreement is replaced by the amended Administrative
Summary attached hereto as Exhibit B and made a part of this Amendment No. 3.
5. Section IV, Payment of Compensation and Fees, is amended to state: Contractor’s compensation
and fees as more fully described in Exhibit B of the Agreement and Exhibit A of this Amendment
No. 3 for performance of the services approved and accepted by the City under this Agreement
shall not exceed $2,190,000 per year for the fixed cost of administrative and stop loss fees for
the term of this Amendment No. 3.
6. All other terms and conditions of the Agreement remain unchanged and in full force and effect.
If a conflict or ambiguity arises between this Amendment No. 3 and the Agreement, the terms
and conditions in this Amendment No. 3 prevail and control.
IN WITNESS WHEREOF, the Parties have entered into this Amendment on the Effective Date.
FOR THE CITY FOR THE CONTRACTOR
By: _________________________________________ By: _________________________________________
Its: Mayor Its: _________________________________________ Vice President, Commercial Sales
APPROVED AS TO FORM:
By: _________________________________________
City Attorney
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Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
ATTEST:
By: _________________________________________
City Clerk
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Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit A
Legal Name of Group: CITY OF CHANDLER
Effective Date: 01/01/2027 - 12/31/2027 Group Number(s): 028399 Current Date: 9/4/2026
Strategic Rel. Executive: Christie Thomas Funding: 12/24 Incurred ASC with Medical and Pharmacy Days Notice: 270
Underwriter: Brian Cohen Total Enrollment: 1,934 Specific Stop Loss Limit: $350,000
Broker: SEGAL COMPANY ARIZONA INC: RACHEL MARIE CALISI Commission (% of Billed Rate): 0.000% Aggregate Stop Loss Limit: 125%
Commission: 0.000% Dental Coverage: No
SOLD BENEFITS Benefit Descriptions Grandfathered Status
PPO 1000 80 Red INET: Ded $1,000/$2,000; 80%; OOP $4,000/$8,000; OV $25/$40; ER $100 Ded+80%; UC $50; Rx $15/$60/$80/$140 2x MOD; N: Non-Grandfathered
ONET: Ded $3,000/$6,000; 50%; OOP $8,000/$16,000
PPO 2000 80 Blue INET: Ded $2,000/$4,000; 80%; OOP $5,000/$10,000; OV/UC Ded+80%; ER $100 Ded+80%; Rx $15/$60/$80/$140 2x MOD; N: Non-Grandfathered
ONET: Ded $5,000/$10,000; 50%; OOP $10,000/$20,000
HSA 3000 80 White INET: Ded $3,000/$6,000; 80%; OOP $6,000/$12,000; OV/ER/UC Ded+80%; Rx $15/$60/$80/$140 2x MOD; N: Non-Grandfathered
ONET: Ded $6,000/$12,000; 50%; OOP $12,000/$24,000
Sold Rates Effective 01/01/2027
PPO 1000 80 Red Enrollment Admin SSL $350K ASL 125% Commission Other Fixed Cost ICAP Exp Liab Max Liab
Employee 199 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $1,354.42 $1,228.46 $1,499.34
Employee + Spouse 166 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $2,335.82 $2,013.58 $2,480.74
Employee + Child(ren) 97 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $2,057.53 $1,790.94 $2,202.45
Employee + Family 222 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $3,420.66 $2,881.45 $3,565.58
Total Plan 1 684 $23,803 $73,229 $2,093 $0 $0 $99,125 $1,616,243 $1,392,121 $1,715,368
PPO 2000 80 Blue Enrollment Admin SSL $350K ASL 125% Commission Other Fixed Cost ICAP Exp Liab Max Liab
Employee 37 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $1,293.67 $1,179.86 $1,438.59
Employee + Spouse 17 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $2,231.10 $1,929.80 $2,376.02
Employee + Child(ren) 12 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $1,965.31 $1,717.17 $2,110.23
Employee + Family 19 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $3,267.34 $2,758.79 $3,412.26
Total Plan 2 85 $2,958 $9,100 $260 $0 $0 $12,318 $171,458 $149,484 $183,776
HSA 3000 80 White Enrollment Admin SSL $350K ASL 125% Commission Other Fixed Cost ICAP Exp Liab Max Liab
Employee 425 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $1,045.58 $981.38 $1,190.50
Employee + Spouse 157 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $1,803.23 $1,587.50 $1,948.15
Employee + Child(ren) 118 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $1,588.38 $1,415.62 $1,733.30
Employee + Family 465 $34.80 $107.06 $3.06 $0.00 $0.00 $144.92 $2,640.70 $2,257.48 $2,785.62
Total Plan 3 1,165 $40,542 $124,725 $3,565 $0 $0 $168,832 $2,142,833 $1,883,095 $2,311,665
PEPM Account
Sold CDH Account Pricing PEPM (Not Included Above)
Fees
HSA 3000 80 White Health Savings Account $2.70
CDH Annual Account Setup Fee (Not Included Above) # of Accounts Annual Fee
Annual account setup fee is billed by CDH and is based on the total number of HRA and FSA plans. 0 - 499 $250
500 - 2,999 $500
3,000 + $1,500
Employers selecting Consumer-Directed Healthcare (CDH) Account Administration (including integration), for account types; HSA, HRA, FSA, DCFSA & LPFSA, hereby direct BCBSAZ to collect the
administration fees and forward the proportional fees to HealthEquity for services, along with the required personal health information. BCBSAZ collects CDH Account administration fees and is not responsible
for any reconciliation, recoupment or adjustments to payments received and forwarded to on behalf of Employer.
Employer agrees to pay for charges for CDH administration services. For HSA and HRAs, these charges apply to all employees enrolled in a health plan the group has paired with a CDH account. For FSAs,
those charges apply to any employee for whom an FSA election has been sent to BCBSAZ by the employer.
Monthly PEPM Fees One-Time Fee /
Sharecare Account Summary Effective Date Non-Enrollees Employee EE + Spouse EE + Child(ren) EE + Family Non-Enrollees
Basic 1/1/2027 No $0.00 $0.00 $0.00 $0.00 $0
Proposed administration assumes BCBSAZ will retain Rx Rebates. In exchange for retaining Rx Rebates, BCBSAZ has adjusted the Admin PEPM by the Rx Rebate Credit. Rx Rebate Credit (PEPM) = $32.90.
In addition to the Rx Rebate Credit (PEPM), BCBSAZ is also providing a rebate share agreement based on utilization of brand name drugs eligible for rebates. Please see the assumptions for details.
Premium tax is NOT included in the specific and aggregate charges.
Minimum Monthly Attachment Level: $3,537,480.
Fixed Expenses = Admin Charges + Stop Loss Premium + Commission (if applicable). Exp Liab = Fixed Expenses + ICAP/Aggregate Corridor. Max Liab = Fixed Expenses + ICAP.
$80,000 Wellness allowance, $100,000 Other allowance, $25,000 General Fund allowance, and $5,000 Other allowance are included. See Assumptions for details.
Administrative rate guarantee is included. See Assumptions for details.
Mayo is not included as an in-network provider.
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Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Consumer-Directed Healthcare (CDH) services were purchased and will be billed as an additional charge to the above premium rates. See the CDH rate exhibit for details.
Chiropractic Capitation: $3.22 PMPM. UM Services: excluded. Value Based Services: included.
Out-of-Network Shared Savings: 30% with $10,000 cap per claim.
Sharecare (Basic): included. See Assumptions for details.
Rx coverage through BCBSAZ: Yes. Rx applies to stop loss products: Yes.
Subrogation: Included.
Rx Formulary: Open.
84% of the members on the enrollment census live within a 20-mile radius of a Prosano facility.
BCBSAZ standard hourly rate for requests for information: $250/hour (no charge for first 5 hours).
All information from the exhibit Assumptions IASC-2027-028399-14, Administrative Summary, and Disclosure of 'Eligible Indirect Compensation' (Exhibit 1) incorporated herein by reference.Employer
acknowledges electronic receipt of the Uniform Summaries of Benefits and Coverage (SBCs) for plans selected and the SBCs are incorporated herein by reference.
BCBSAZ reserves the right to adjust these premium rates retroactive to the first day of any billing month in which enrollment varies by more than fifteen percent (15%) from that listed above.
The ACA prohibits waiting periods in excess of 90 days. By signing below you represent that you do not impose a waiting period which is longer than 90 days and that you have made all necessary changes to
bring all waiting periods for your plan into compliance with the ACA requirements. You agree to promptly advise BCBSAZ of any change which may impact the accuracy of this representation. You agree to
provide BCBSAZ with timely and accurate information regarding enrollee effective dates and shall ensure such effective dates comply with applicable laws.
This Rate Acceptance Form must be signed and returned prior to BCBSAZ issuing ID Cards. If any information on this Form is inaccurate, please provide the correct information on this Form.
9/4/2026
BCBSAZ Representative Date Group Representative Signature Group Representative Title Date
APPROVED AS TO FORM:
By: __________________________________
City Attorney
ATTEST:
By:__________________________________
City Clerk
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Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
CITY OF CHANDLER
Group Number(s): 028399
Renewal Period: 01/01/2027 - 12/31/2027 Assumption: IASC-2027-028399-14
Blue Cross Blue Shield of Arizona (BCBSAZ) Assumptions
GENERAL
* BCBSAZ may adjust rates if the following requirements are not met:
Where the employer contributes 100% of the employee cost, BCBSAZ requires 100% participation of all eligible employees, excluding those
with other qualifying medical coverage.
Where the employer does not contribute 100%, BCBSAZ requires 70% of all eligible employees to participate.
BCBSAZ requires a minimum of 50% of all full-time eligible employees in the group to be enrolled in the employer's group plan.
Employer must contribute a minimum of 50% of the employee's health premium.
Payroll deduction for employee contribution is required.
* Rates assume BCBSAZ is the sole medical and Rx carrier.
* BCBSAZ reserves the right to re-evaluate the rates if there is a significant change in the rating assumptions (e.g. enrollment).
* BCBSAZ reserves the right to re-evaluate and change the rates if City of Chandler adds or deletes a benefit eligible class that will have BCBSAZ medical
coverage.
* We have not included premium tax on this account, based on the assumption that all premiums are paid with the employer's funds, and the employer is a
municipality.
* Notwithstanding anything to the contrary in the Agreement, nothing in this Agreement shall restrict Group’s ability to access or share the information specified
in ERISA Section 724 (commonly referred to as the No Gag Clause provision) for the purposes permitted in ERISA Section 724.
* Beginning in 2015 the Affordable Care Act provides that certain large employers will be subject to a penalty if they fail to offer full-time employees and certain
dependents health coverage which satisfies both a 60% minimum value standard and an affordability requirement and a full-time employee obtains a subsidy
on the health insurance marketplace. Groups subject to these requirements and seeking to avoid a penalty are responsible for the ultimate determination of
whether the minimum value and affordability requirements are satisfied. Using the minimum value calculator made available by HHS and the IRS, BCBSAZ
estimates that the minimum value of PPO 1000 80 Red, PPO 2000 80 Blue, HSA 3000 80 White do meet the minimum value standard. It is important that
you independently review and confirm these results as they may be impacted by information not available to us (for example, benefits not provided by
BCBSAZ, non-standard benefits not suited for the calculator and certain HSA contributions or HRA funds). BCBSAZ has included its conclusion(s) about
minimum value in the plan(s) SBC(s) that BCBSAZ provides to Group. Any changes that Group makes to that conclusion based on Group’s independent
analysis will also affect the minimum value statement(s) in the SBC.
* To view compensation BCBSAZ may receive if you purchase certain third-party products, visit azblue.com/compensation
* Charges will apply for requested vendor integrations and file exchange requests. Specifically, a custom file will incur a charge of $12,000, while a standard file
will incur a charge of $5,000. These charges will be billed via the claim invoice. As an option, General, Implementation, Technology, or Other funds can cover
the charges. For vendor integration related to RX and/or Stop Loss, the charges will be covered by the associated carve-out fees.
PHARMACY
* The Plan Sponsor is responsible for design of the Plan, including any modification or termination of the Plan, and retains sole and complete control to select
and change the formularies for its Plan.
If BCBSAZ receives pharmacy rebates attributable to pharmaceutical products covered under the terms of this Agreement and used by Participants of
Employer’s Plan, BCBSAZ will pay Employer the following amounts for brand prescriptions filled, excluding AMPCAP drugs, and for which BCBSAZ received
a rebate:
30 days retail - $50.00 per eligible brand script,
90 day retail - $203.00 per eligible brand script,
Mail Order Delivery - $219.00 per eligible brand script,
Specialty Home Delivery - $565.00 per eligible brand script.
Employer acknowledges that it accepts these amounts and that it and its group health plan have no right to, or legal interest in, any rebates provided by
pharmaceutical manufacturers to BCBSAZ.
* If BCBSAZ receives any rebates attributable to pharmaceutical products covered under the Medical Benefit Agreement, and used by Participants of
Employer’s Plan, BCBSAZ shall retain any such rebates and shall not remit any rebate payments to Employer.
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Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
CITY OF CHANDLER
Group Number(s): 028399
Renewal Period: 01/01/2027 - 12/31/2027 Assumption: IASC-2027-028399-14
PBM PRICING MODEL: Pharmacy Network discounts are negotiated between BCBSAZ and our pharmacy benefit manager (PBM) over BCBSAZ’s entire
book of business and not on behalf of any group customer. You have selected the pass through PBM pricing model effective 1/1/2027. The pass through
PBM pricing model allows you to pay the same discounted prices for prescription drugs that the PBM actually pays the pharmacies. Prices for the same drug
may differ at different pharmacies. The Pass Through PBM pricing model passes on to you 100% of the specific pharmacies' network discount. However, it
does not allow the PBM to lower the prices for expensive drugs by applying savings realized elsewhere. Any projected savings discussed with you that may
result from this pricing are only estimates. Your actual savings may vary from these estimates.
FUNDING
* Rates assume BCBSAZ is the sole Specific and Aggregate Stop Loss carrier.
* BlueCard fees are included in the Attachment Point rate (if applicable) and are charged on the monthly invoice as a claim expense.
* The Specific Stop Loss level is $350,000 per person per policy year.
* Independent Dispute Resolution (IDR) Fees
Independent dispute resolution (IDR) is a process for determining payment rates for out-of-network health care charges for claims that qualify for protections
under No Surprise Billing legislation. There are two types of fees charged for IDRs: 1. Administrative Fee - currently $115/party/dispute, paid by both parties.
2. IDR Entity Fee - currently $200-$840 for single determinations, $268-$1,173 for batched determinations up to 25, and $75-$250 for each additional
increment of 25, paid by the losing party. Because claims can be batched, BCBSAZ pro-rates the fees when only a portion of the claims are attributable to
any specific group.
* BCBSAZ will continue to process claims incurred during the renewal term of the Agreement (January 1, 2027 - December 31, 2027 for a period of 24 months
after the end of the renewal term. Stop loss coverage will apply to claims incurred during the renewal term and paid during the renewal term or within 24
months after the end of the Renewal Term. If the Agreement is terminated before December 31, 2027, the foregoing 24 month periods shall start on the
effective date of the termination of the Agreement. BCBSAZ's obligations are contingent upon Employer satisfying its payment obligations.
DISCLOSURE
* Costs for covered services provided by a chiropractor to PPO, EPO, HMO and indemnity members, including an allowance for BCBSAZ to maintain this
arrangement, will be paid by the Employer to BCBSAZ on a per member per month (PMPM) basis. The PMPM rate each Employer pays BCBSAZ will differ
from the capitated fee BCBSAZ negotiated with the chiropractic administrator. BCBSAZ negotiated the fee that BCBSAZ pays the chiropractic administrator
on the basis of BCBSAZ’s entire book of business, without regard to any individual Plan. The PMPM rate BCBSAZ charges the employer is subject to change
by BCBSAZ upon 60 days prior written notice. The PMPM rate for chiropractic services applicable to this Employer is $3.22 PMPM. Any difference between
this amount and the amount paid to the chiropractic administrator will be reflected on the employers Form 5500 Information (if BCBSAZ provides one). The
fee BCBSAZ pays may be adjusted at any time as a result of modifications to the contract between BCBSAZ and chiropractic provider. Additionally, the fee
may be decreased in a given year if a set claims to capitation ratio is not achieved. Neither of these adjustments to the fee BCBSAZ pays would result in
adjustment to the fee applicable to Employer.
* Third Parties: BCBSAZ charges a per member per month (PMPM) or other specified amount for certain services provided by third-parties which includes an
allowance for BCBSAZ to maintain these arrangements. This PMPM or other amount may be different than the amount BCBSAZ pays the third-party and
BCBSAZ will retain any difference as reasonable compensation for services provided. In some cases, the amount retained by BCBSAZ and received by the
third-party is a percentage of the savings or recoveries generated by the third-party services. Certain of these third-party contractual arrangements may
involve reconciliation processes or other adjustments which may further change the amount paid to the third-party or retained by BCBSAZ. The rate BCBSAZ
charges the employer is subject to change by BCBSAZ upon 60 days prior written notice. The fee BCBSAZ pays may be adjusted at any time due to
modifications of the contract between BCBSAZ and the third-party. BCBSAZ negotiates the fees it pays these third-parties on the basis of BCBSAZ’s entire
book of business, without regard to any individual plan.
* BCBSAZ Value Based Programs
Value-Based Program (VBP) is outcome-based payment arrangement and/or a coordinated care model facilitated with one or more local providers that is
evaluated against cost and quality metrics/factors and is reflected in provider payment.
LOCAL - BCBSAZ pays some of its contracted medical providers an amount to manage the medical care of members diagnosed with certain medical
conditions if the provider demonstrates to BCBSAZ it has satisfied BCBSAZ’s criteria for effectively managing the care (“Value Based Services”).
With respect to BCBSAZ group members residing and receiving Value Based Services in Arizona under a BCBSAZ value based program, BCBSAZ will
estimate at the beginning of the contract year the amount BCBSAZ projects it will pay BCBSAZ’s contracted providers for members who receive Value Based
Services throughout the upcoming year in the form of a PMPM or PEPM charge (“PMPM Charge”). BCBSAZ will charge BCBSAZ’s self-insured (“ASC”)
Groups via the Employer’s Claims Invoice this PMPM Charge beginning January 1, 2016.
On an aggregate basis for the entire Value Based Program, the amounts used to calculate PMPM charge are fixed amounts estimated to be necessary to
finance the cost of a particular Value-Based Program. Because amounts are estimates, there may be positive or negative differences based on actual
experience, and such differences will be accounted for in a variance account maintained by BCBSAZ until the end of the applicable Value-Based Program
payment and/or reconciliation measurement period. The amounts needed to fund a Value-Based Program may be changed before the end of the
measurement period if it is determined that amounts being collected are projected to exceed the amount necessary to fund the program or if they are
projected to be insufficient to fund the program.
On an aggregate basis for the entire Value Based Program, at the end of the Value-Based Program payment and/or reconciliation measurement period
for these arrangements, BCBSAZ will do one of the following:
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Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
CITY OF CHANDLER
Group Number(s): 028399
Renewal Period: 01/01/2027 - 12/31/2027 Assumption: IASC-2027-028399-14
a. Use any surplus in funds in the variance account to fund Value-Based Program payments or reconciliation amounts in the next measurement period.
b. Address any deficit in funds in the variance account through an adjustment to the PMPM billing amount or the reconciliation billing amount for the next
measurement period.
NOTE: If an ASC Group terminates its BCBSAZ contract, that Employer will neither receive a refund nor a charge to reflect any variance between what
BCBSAZ charged the Employer in Value Based Charges and what BCBSAZ paid the providers for Value Based Services.
NATIONAL - Value Based Services will also apply to your members who reside in other states/geographical locations served by other Blue Cross Blue Shield
Plans. A full description of these arrangements will be described in your contract.
Inter-Plan Arrangements Fees:
BlueCard Program Fees
Access Fees:
· 1.74% in 2027 for 1,000–9,999 Blue PPO, EPO (Self-Funded Group Health Plans Only) or traditional enrolled contracts of network savings, capped at
$2,000.00 per claim
Reduced Administrative Expense Allowances (AEAs) – To be considered for reduced fees, the Employer must exceed 1,000 PPO, EPO (Self-Funded Group
Health Plans Only) or traditional enrolled Blue contracts:
· Professional - $4.00 per claim
· Institutional - $9.75 per claim
· Non-Participating Provider $3.00 per claim
· Medicare related claims $1.00 per claim
· Non-standard negotiated fees can range from either $5.48 to $15.44 per claim or $8.50 to $21.10 per contract per month depending on the negotiated
arrangement and/or the health plan product.
* Out-of-Network Shared Savings
BCBSAZ developed and maintains a proprietary fee schedule and utilizes claim editing software to calculate the Allowed Amount. Costs for calculating the
Allowed Amount for Out-of-Network Services will be paid by the Employer to BCBSAZ on a percentage of claims savings basis. The cost for this service is
30% of claims savings with $10,000 cap per claim. This cost will not be applied to Group's ASL and/or SSL. BCBSAZ has hired a third party to attempt
negotiation of reimbursement and member protection from balance billing for Out-of-Network Services.
* Sharecare: For certain Sharecare programs that Employer has specifically elected to purchase, BCBSAZ charges an amount per person which may be
based upon employee count, member count or program participation depending on the specific program purchased. These charges will be included in the
monthly claims invoice and may be different than the amount BCBSAZ pays Sharecare. BCBSAZ will retain any difference as reasonable compensation for
services provided. For the Sharecare Incentive Reward Program, BCBSAZ will charge Employer the amount of the award plus any applicable administrative
fees and include this charge in the monthly claims invoice. The rates BCBSAZ charges Employer for the Sharecare programs are subject to change by
BCBSAZ upon 60 days’ prior written notice. BCBSAZ negotiates fees with Sharecare on the basis of BCBSAZ’s entire book of business, without regard to any
individual plan. The one-time setup fees are built into the admin rate as a PMPM (per member per month) charge.
ALLOTMENTS
* BCBSAZ's proposal includes a(n) Wellness allowance of $80,000 for the 01/01/2027 - 12/31/2027 policy period to be used at the Group’s discretion. Any
portion of the allowance not used during the referenced policy period will be retained by BCBSAZ and applied to wellness programs for subsequent policy
period(s). Upon termination of the group contract, BCBSAZ will return the unused portion of the wellness allowance to the group. If group terms its contract
prior to 12/31/2027, the group will be required to return a prorated amount of the disbursed funds. BCBSAZ reserves the right to re-rate and adjust the
allowance amount as a result of the loss of any of the bundled products.
* BCBSAZ's proposal includes a(n) Other allowance of $100,000 for the 01/01/2027 - 12/31/2027 policy period to be used at the Group’s discretion. Any portion
of the allowance not used during the referenced policy period will be retained by BCBSAZ and applied to other programs for subsequent policy period(s).
Upon termination of the group contract, BCBSAZ will return the unused portion of the other allowance to the group. If group terms its contract prior to
12/31/2027, the group will be required to return a prorated amount of the disbursed funds. BCBSAZ reserves the right to re-rate and adjust the allowance
amount as a result of the loss of any of the bundled products.
* BCBSAZ's proposal includes a(n) General Fund allowance of $25,000 for the 01/01/2027 - 12/31/2027 policy period to be used at the Group’s discretion. Any
portion of the allowance not used during the referenced policy period will be retained by BCBSAZ and applied to general fund programs for subsequent policy
period(s). Upon termination of the group contract, BCBSAZ will return the unused portion of the general fund allowance to the group. If group terms its
contract prior to 12/31/2027, the group will be required to return a prorated amount of the disbursed funds. BCBSAZ reserves the right to re-rate and adjust
the allowance amount as a result of the loss of any of the bundled products.
* BCBSAZ's proposal includes a(n) Other allowance of $5,000 for the 01/01/2027 - 12/31/2027 policy period to be used at the Group’s discretion. Any portion of
the allowance not used during the referenced policy period will be retained by BCBSAZ and applied to other programs for subsequent policy period(s). Upon
termination of the group contract, BCBSAZ will return the unused portion of the other allowance to the group. If group terms its contract prior to 12/31/2027,
the group will be required to return a prorated amount of the disbursed funds. BCBSAZ reserves the right to re-rate and adjust the allowance amount as a
result of the loss of any of the bundled products.
GUARANTEES
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Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
CITY OF CHANDLER
Group Number(s): 028399
Renewal Period: 01/01/2027 - 12/31/2027 Assumption: IASC-2027-028399-14
On-site
* BCBSAZ agrees to an administrative rate guarantee for 1/1/2028 - 12/31/2030. Wellness Wellness General Other
PEPM Increase Allowance Consultant Fund Allowance
1/1/2028 - 12/31/2028 Net Administration Rate $35.85 3.0% $80,000 $100,000 $25,000 $5,000
1/1/2029 - 12/31/2029 Net Administration Rate $36.92 3.0% $80,000 $100,000 $25,000 $5,000
1/1/2030 - 12/31/2030 Net Administration Rate $38.03 3.0% $80,000 $100,000 $25,000 $5,000
This guarantee is contingent upon BCBSAZ being selected as the sole stop loss carrier (Specific and Aggregate) for the entire policy period 1/1/2028 -
12/31/2030 (3 years).The rate guarantee excludes any Allotments, Claim Deposit Credits, which will be subject to pricing information at the time of each
renewal. This guarantee assumes BCBSAZ retains all Rx rebates during the time of the guarantee. Guaranteed administration rates assume all quoted
benefit plans remain Rx rebate eligible throughout the guarantee period. BCBSAZ reserves the right to change the rate guarantee due to legislative changes.
Total enrollment changes do not exceed +/-15%. Total enrollment as of Feb 2026 is 1,934 subscribers and 4,928 members.
028399 - 2 Page 6 of 6

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
CITY OF CHANDLER
PERFORMANCE GUARANTEES
Vendor Name Blue Cross® Blue Shield® of Arizona (BCBSAZ)
Contact Name Christie Thomas
Contact Title Strategic Relationship Executive
Contact Number (602) 864-5234
Authorized Signature See original for signature.
PERFORMANCE GUARANTEES
VENDOR RESPONSE
(ALL PROPOSERS)
For the following categories, provide the performance standard you
Agree to comply with
are willing to offer, the financial penalty (maximum dollar amount Measurement Dollars at Risk
Performance
or % of administrative fees) you will agree to pay if the standard is Frequency (% or $)
Guarantee?
not met, and the method of measuring the penalty.
(Y | N)
1. Vendor attendance at District meetings Quarterly

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Attendance by vendor representatives when requested at
meetings scheduled by the City of Chandler during the
contract period and implementation phase.
BCBSAZ Alternative Recommendation: BCBSAZ proposes
the Account Management Performance Guarantee.
Standard: Overall score of 3 (satisfied) or better on the
BCBSAZ Account Management Score Card (annual Group 2% of annual
Measured annually Yes
Benefit Administrator survey) – see attached. admin fee
Desired Qualifiers: Categories include: effective support for
open enrollment events, timely client notification of issues
impacting members, response to client issues and questions
in timely, comprehensive manner, effective coordination to
resolve open issues, accessibility, and delivery of agreed-
upon reports on time.
Group specific
2. Vendor call (or e-mail) return timeliness Quarterly
City of Chandler or designated consultant’s calls (or e-mails)
to vendor are returned within 48 business hours.
BCBSAZ Alternative Recommendation: BCBSAZ proposes See #1 above. Yes See #1 above.
combining PGs 1 and 2 under the Account Management
guarantee, which guarantees ongoing communication and
support activities, including accessibility.
3. Processing monthly eligibility updates Monthly
All updates to eligibility or enrollment records will be made
within three business days after the information is received by
the vendor.
2% of annual
BCBSAZ Alternative Recommendation: Standard: 99% of Measured quarterly Yes
admin fee
valid electronic eligibility files are processed within five
business days of receipt of complete and accurate
information during initial implementation.
Group Specific
4. Telephone call availability & answering speed Monthly

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
90% of all calls are answered within 30 seconds, and
telephone service is available between 8:00 am and 6:00 pm
Arizona Time Zone on business days.
BCBSAZ Alternative Response: Standard: BCBSAZ
Customer Service calls answered in an average of 45 2% of annual
Measured quarterly Yes
seconds or less. admin fee
Desired Qualifier: Average speed of answer begins once the
caller exits the IVR.1
Non-Group specific
Customer Service hours are 6 a.m. to 6 p.m. (Arizona time),
Monday through Friday.
5. Telephone call on-hold (in-queue) time Monthly
An average of less than 2 minute(s) on hold before a human
being answers.
See #4 above. Yes See #4 above.
BCBSAZ Alternative Recommendation: This guarantee is
combined with PG #4 (telephone call availability and
answering speed).
6. Telephone Abandonment Rate Monthly
An abandonment rate of less than 3% is maintained during
standard business hours.
BCBSAZ Alternative Recommendation: Less than 5% of 2% of annual
BCBSAZ Customer Service calls abandoned. Measured quarterly Yes admin fee
Desired Qualifier: Call abandonment rate applies to calls
abandoned once the caller enters the call queue.1
Non-Group specific
7. Claims Processing Accuracy Quarterly

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
99% of claims dollars submitted for payment will be
accurately processed and paid. Regardless of whether or not
these standards of performance are satisfied, the vendor
must reimburse the City of Chandler for all overpayments that
are not recovered from the recipient within 60 days after the
overpayment is discovered. City of Chandler will assign its
right to recover such overpayments to the vendor.
2% of annual
BCBSAZ Alternative Recommendation: Standard: 98% of Measured quarterly Yes admin fee
audited1 claims dollars are paid in accordance with benefit
plan designs and in-force provider contracts.
Desired Qualifier: This penalty applies if BCBSAZ fails to
perform in accordance with this standard two (2) consecutive
reporting periods. A penalty pay out of half of the fees at-risk
would occur for results at or below 97.5%.1
Non-Group specific
8. Turnaround Time on Claims Payments Quarterly

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
95% of all claims received will be completely processed
(paid, denied or pended for additional information) within 14
calendar days after they are received. 100% of claims will be
processed within 30 calendar days of receipt.
BCBSAZ Alternative Recommendation: Standard: 90% of
non-investigated clean claims processed (paid or rejected)
within 14 calendar days after receipt of clean claim.1 2% of annual
Measured quarterly Yes
Desired Qualifier: A claim is defined as a request for a admin fee
payment of a plan benefit by a plan participant or health care
provider; a claim is deemed received when it has been time-
stamped by BCBSAZ. Claims pended for missing information
or benefit eligibility will be included as a documented claim.
Non-Group specific.
Claims processing penalties are not applicable on claims
incurred outside of Arizona.
9. Timeliness of Claim Reports Annually
Each report the vendor will supply City of Chandler will be
provided within a mutually agreed upon timeframe but no later
than the 10th of the month following.
BCBSAZ Alternative Recommendation: Standard: Monthly 2% of annual
Measured annually Yes
standard reports will be delivered on time. admin fee
Desired Qualifier: Delivery of standard reports: whYzen-
BlueInsightSM, our self-serve online reporting tool is available
online, and updated the 20th of the month.
Group specific
10. Claims Coding Annually

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
98% of all claims will be coded with no errors.
BCBSAZ Alternative Recommendation: Standard: 95% of
audited claims are processed in accordance with benefit plan
2% of annual
designs.1 Measured quarterly Yes
admin fee
Desired Qualifier: Percentage of claims processed
incorrectly vs. correctly, based on BCBSAZ standard auditing
procedures.
Non-Group specific
11. Implementation (if appropriate) Annually
Successful implementation as defined by key milestones.
Include measurable milestones in your proposal.
BCBSAZ Alternative Recommendation: Standard: BCBSAZ
will complete a successful implementation as defined by key Measured 90 days
milestones. after effective date and 2% of annual
Yes
Desired Qualifier: BCBSAZ agrees to meet milestones as paid out 120 days after admin fee
outlined on the proposed implementation timeline (See effective date.
Section 5). Note: the current proposed implementation
timeline will be agreed upon and finalized during initial
implementation meetings.
Group specific
12. Data Exchange Annually
Receive and transmit data with vendors based on a
frequency defined by the business needs of the City of
Chandler.
BCBSAZ Alternative Recommendation: Standard: BCBSAZ
will receive and transmit data with vendors based on a 2% of annual
TBD Yes
frequency defined by the business needs of Client. admin fee
Desired Qualifier: Should BCBSAZ interface with any
independent vendors to service client, we agree to establish
appropriate mutually agreeable performance standards for
data transmission.
TBD

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Comments
Total of all risk measures cannot exceed 20% (based on administrative fee only).
1 If BCBSAZ fails to perform in accordance with these guarantee(s) for two (2) consecutive reporting periods after the guarantee(s) are
effective, BCBSAZ will refund or credit the group up to the amount at risk per measure during the time period which BCBSAZ did not meet
the performance guarantee(s).
Additional BCBSAZ Notes:
1. The above stated performance guarantees will be effective for the contract period 1/1/2027 to 12/31/2027.
2. The performance guarantee payout does not include stop loss premiums, claims reimbursement amounts, vendor interface fees,
capitated claim payments, etc.
3. Performance guarantees are reported to the client approximately 90 days after the close of the measurement period or plan year. Payout
is made (if applicable) after the reporting of results.
4. BCBSAZ will not be required to pay a penalty for performance guarantees if the group is in default of its contract with BCBSAZ and/or
has not paid all claims and premiums by the date due.
5. BCBSAZ will determine the sample size of audited claims.
Unauthorized replication or use of this financial workbook is prohibited.
Copyright © 2022 by Segal. All rights reserved.

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Client Information
Renewal Effective Date January 01, 2027
Client Name and Group Number
AZ Blue Group Number(s) 028399
Legal Account Name City of Chandler
Doing Business As City of Chandler, Arizona
Legal Entity Type Municipality
Type of Business City
Client Headquarter Address
Headquarter State Arizona
Incorporated State Arizona
Street Address 175 S. Arizona Avenue
City, State, Zip Code Chandler, AZ 85225
Group Benefit Administrator (GBA)
*Day to day contact for AZ Blue*
*If the address is different from the Headquarter address, please provide
Name Fernanda Acurio
Title Human Resources Manager
Phone 480-782-2359
Email Fernanda.Acurio@chanderaz.gov
Name Kristin Maier
Title Director of Human Resources
Phone 480-782-2351
Email Kristin.Maier@chandleraz.gov
Group Executive
*If the address is different from the Headquarter address, please provide
Name Kristin Maier
Title Director of Human Resources
Phone 480-782-2351
Email Kristin.Maier@chandleraz.gov
Chief Executive Officer
*If the address is different from the Headquarter address, please provide
Name John Pombier
Title Acting City Manager
Phone 480-782-2211
Email John.Pomier@chandleraz.gov
Chief Financial Officer
*If the address is different from the Headquarter address, please provide
Name Dawn Lang
Title Deputy City Manager – Chief Financial Officer
Phone 480-782-2255
Email Dawn.Lang@chandleraz.gov
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Product Information
Member ID Number Issuance Included
(Generated by AZ Blue; includes alternate ID numbers)
Summary of Benefits and Coverage Included
• Draft Summary of Benefits and Coverage
• Review initial drafts with the Client and revise
as agreed
• AZ Blue will provide electronic copies to the
Client/Broker and member portal
• Member SBCs will be available to members in
their MyBlue portal account
Benefit Plan Booklets Included
• Prepare draft Benefit Plan Booklet(s) AZ Blue will provide electronic copies to the Client & Broker and
• Review initial draft(s) with Client post to the member portal
• Revise the initial draft(s) in response to the
Client’s comments and obtain the Client’s
approval of the second draft
• Prepare final Benefit Plan Booklet(s).
• Benefit Plan Booklet(s) will be in English
Assignability of benefits Included
• If a member receives covered services from an
out-of-network provider and the member
wishes to assign the right to payment to the
provider, the member or the provider may
submit the documents requesting assignment.
• AZ Blue, at our sole discretion, will determine
whether to honor the assignment and, if
approved, remit any payment due directly to
the provider
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Account Management Services
Implementation Meeting Schedule Included
Ongoing Account Management Included
• Designated account resources
• Ongoing management and review of
administration, benefits, and data
Open Enrollment Meetings Included
• At locations that meet AZ Blue criteria
(available upon request)
• AZ Blue will attend Open Enrollment meetings
as agreed upon
Annual Consultation Included
• Cost impact of benefit design changes
• Projection of conventional premium equivalent
rates
• Year-end accounting reconciliation
Annual 1099 filings to the IRS (regarding Included
payments to providers)
Provision of data required for 5500 filings Included
Standard Accounting Structure Included
• Individual group numbers for each member of a
Pool, if applicable
• Suffixes to accommodate separate claims
reporting for different benefit plans (i.e., PPO
Plan, HSA Plan, Alliance Plan)
• Claim accounts to accommodate separate
claims data for distinct locations and employee
types (i.e., COBRA, Retiree, School)
Administrative Fee Statements Included
• Statements generated monthly 15 business
days before the due date
• Due date is the first of the month.
• The contract has a grace period of sixty (60)
days for premium payments. If a premium is
not paid on or before the date it is due, it may
be paid during the grace period.
• Billed on a prospective basis
• Option for online or hard copy delivery of
statements
• Ability to view invoices online & download
billing information
• Ability to sort and search for member
information
• Ability to remit payment for Charges for
Covered Services, Administrative Fees, Other
Fees, and any other fees due via ACH, EFT, or
check.
• Includes a full listing of each enrollee,
summary, and total by section
• Discrepancies can be addressed with an AZ
Blue representative
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Administrative Fee Statements Delivery Included
Provided through employer portal. Client will utilize
employer portal to obtain statements.
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Client Administration and Eligibility
Employee Effective Date First of the month (FOM)
Employee Termination Date End of the month (EOM)
Dependent Deletion Age Age 26
(non-disabled dependents)
Dependent Birthday Termination Rule End of the Month
Newborn | Adoptions | Processing Options Newborns are automatically added for the first 31 days after
birth; the member positively enrolls the newborn on the plan
for coverage after 31 days
Newborn Letters Corresponding Newborn letter will be sent
Custom Newborn letter
Domestic Partnership Not Covered
Domestic Partnership Criteria Client-Specific: Employees will be referred to the Group
Benefit Administrator
Retroactive Changes, Reinstatements and Retroactivity is limited to sixty (60) days from the date notice
Terminations was provided to AZ Blue for terminations, changes, and
reinstatements.
Note: AZ Blue has a limited amount of time to request reimbursement
of overpayments from providers per our provider contracts. Clients
electing retro-term grace periods longer than the AZ Blue standard of 31
days are advised that AZ Blue may be unable to attempt overpayment
recovery on some or all overpayments made for terminations more than
31 days from the date of termination. AZ Blue is under no obligation to
reimburse City of Chandler. for any overpayment of claims due to retro
terminations.
Leave of Absence In Accordance with the Group’s policies
Coordination of Benefits (COB) Commercial
The combined payments by the primary payer and AZ Blue will
not exceed the greater of the primary payer or AZ Blue allowed
amount.
Medicare
AZ Blue pays up to the Medicare-allowed amount except if
the provider does not accept Medicare assignment, in which case
AZ Blue pays up to the billed charges.
Appeals Included
AZ Blue administers Level 1, Level 2, and External AZ Blue administers Levels 1, 2, and external.
Review appeals.
Massachusetts Employees AZ Blue will not issue 1099HC or complete electronic filing
with MA
Plan Sponsor will timely provide any authorizations
required by Massachusetts law or by Massachusetts
regulators to enable AZ Blue to perform the mailing
and/or electronic filing(s). If the Plan Sponsor fails to
timely provide such authorization(s), AZ Blue will have
no duty to make the filing and/or mailing.
New York State Health Care Reform Act (HCRA) Elect
NYHCRA
AZ Blue will complete the required filing upon
submission of the required forms. Current or prior
elector status with the NY Pools may impact which
documentation is required to elect and provide AZ
Blue with consent to perform this action on behalf of
an elector.
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Plan Compliance with Mandates – AZ Blue Support Services
AZ Blue will support the Plan’s compliance with the following federal mandates for coverage it administers on behalf of the
Plan Sponsor
• Affordable Care Act Transparency in Coverage rule issued in November 2020 (“Transparency Rule”)
• Certain health plan provisions of the Consolidated Appropriations Act of 2021 (“CAA”).
• Additional services will be mutually agreed upon in writing by AZ Blue and Plan Sponsor.
CAA Provider Directory Requirements Included
• Publish a contracted provider directory on AZ
Blue’s website
• Update and verify the Provider directory every 90
days
• Remove providers whose information cannot be
verified
• Indicate an “accurate as of” date on printed
directories and direct Plan participants to the
online directory.
• Respond within 1 business day to Participant
telephone inquiries regarding provider contractual
relationship with AZ Blue
• Retain responses in the Plan Participant’s file for
two years.
• Apply in-network cost share to covered services
provided in reliance on incorrect provider network
information (if required by CAA).
Transparency Rule Machine Readable Files Included
• Publish legally required machine-readable files
that disclose the Plan’s:
 in-network rates paid to providers
 historical out-of-network allowed
amounts paid to providers
 negotiated rates and historical net prices
for covered prescription drugs
• Make files accessible to both Plan Participants and
Plan Sponsor.
Transparency Rule Cost Tool Included
• Make available a cost-sharing liability tool
consistent with the Transparency-in-Coverage final
rule for the 500 shoppable services identified by
the Centers for Medicare and Medicaid Services
(“CMS”)
• Effective 1/1/23 or the end of any deferred
enforcement period issued by federal regulators
CAA ID Card Requirements Included
• AZ Blue will issue physical or electronic insurance
ID cards w/ deductibles, out-of-pocket maximums,
& telephone number and website address for
individuals to seek consumer assistance
• Issue to all Plan Participants
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Billing Model Notice Included
• Inform Plan Participants about the Plan’s
balance billing protections by providing the
Billing Model Notice to the Plan Sponsor and
posting it to its public website.
Continuity of Care Included
• Apply continuity of care protections when
provider contractual relationships are
terminated.
Prescription Data Reporting Included
• Submit to CMS specified files for the
Prescription Drug Data Collection (RxDC) AZ Blue’s obligations to submit any files for the Plan Sponsor
required by the CAA and implementing are contingent upon the Plan Sponsor providing AZ Blue all
regulations information AZ Blue requests by the dates and in the formats
• If AZ Blue administers the Plan Sponsor’s AZ Blue’s specifies in its information collection materials. AZ
prescription drug benefit, submit the following Blue will not provide any RxDC information for the Plan for any
files: period of time during the applicable calendar year that the
o P1 Individual and Student Market Plan Plan Sponsor was not a Client of AZ Blue. AZ Blue reserves the
List OR P2 Group Health Plan List right to modify supported reporting upon sixty (60) days’ prior
o D1 Premium and Life Years written notice to Plan Sponsor.
o D2 Spending by Category
o D3 Top 50 Most Frequent Brand Drugs
o D4 Top 50 Most Costly Drugs
o D5 Top 50 Drugs by Spending
Increase
o D6 Rx Totals
o D7 Rx Rebates by Therapeutic Class
o D8 Rx Rebates for the Top 25 Drugs
o Narrative Response
• If AZ Blue does not administer the Plan
Sponsor’s prescription drug benefit, submit
the following files:
o P1 Individual and Student Market Plan
List OR P2 Group Health Plan List
o D1 Premium and Life Years
o D2 Spending by Category
o Narrative Response (if applicable)
Other Included
• For coverage it administers for the Plan
Sponsor, AZ Blue will submit to HHS air
ambulance claim data consistent with the CAA
and implementing regulations.
• For coverage it administers for the Plan
Sponsor, AZ Blue will submit an annual Gag
Clause Prohibition Compliance Attestation
consistent with CAA requirements
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Vendor Details
Inbound Eligibility Vendor
Vendor or Trading Partner Name City of Chandler
Contact Dee Hooker
Phone 480-782-2371
Email Denise.Hooker@chandleraz.gov
COBRA Vendor Contact
Vendor or Trading Partner Name Alight
Contact Shaun Smith
Phone 410-568-2351
Email Shaun.Smith.3@alight.com
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
Client Customization(s)
Custom Benefit Book Information • City of Chandler has a custom "Plan
Administration" section for all plans.
• Changes to Your Information should refer the
member to City of Chandler Human Resources
for changes. Last bullet of that section should
state "An unmarried disabled Dependent age 26
or older who is no longer disabled"
• Definitions, Eligibility Requirements, Effective
Date of Coverage, Loss of Eligibility, Retiree
eligibility, Special Enrollment Periods,
Termination of Coverage and Leave of Absence
should contain no language. Instead, include the
note "Refer to City of Chandler policy for
[Definitions]" where the bracketed information
refers to the name of the section. Headings and
language for Continuation of Coverage,
Disability Extension of Benefits, Medical Suppor
Orders, Benefit-Specific Eligibility should
continue to be included in the booklets.
Retiree Coverage • As of January 1, 2024, the City mandates
Medicare enrollment for retirees and their
dependents who become Medicare-eligible in
order to remain eligible for continued coverage
under the City of Chandler medical plan. Retirees
and their dependents who became Medicare-
eligible before January 1, 2024, but did not
enroll in Medicare are grandfathered and remain
eligible for medical plan coverage.
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Exhibit B
Administrative Summary
IMPORTANT - READ CAREFULLY
As the authorized representative of Plan Sponsor, I certify and agree to the following:
• Information provided in this Administrative Summary and all other applicable documents
submitted in connection with this Administrative Summary are complete and accurate.
• If the information contained in the Administrative Summary or other supporting
documentation is incomplete, inaccurate, materially misleading, false, or fraudulent, AZ Blue
has the right to:
 retroactively adjust the Plan Sponsor’s Administrative Fees or Other Fees if such
information would have affected the Fee calculation;
 invalidate, or withdraw any Fee proposal, or terminate coverage to the extent
permitted by the Agreement or applicable federal or state law.
• This Administrative Summary is not accepted until approved by AZ Blue and AZ Blue’s
acceptance shall be based on information supplied by the Plan Sponsor, the requested
benefits, and any other information obtained from outside sources.
• This Administrative Summary shall become binding upon AZ Blue and the Plan Sponsor. Upon
acceptance, this Administrative Summary shall be attached to and shall become a part of the
Agreement.
• By including my e-mail address in the Administrative Summary, I authorize AZ Blue to send
information to the Plan Sponsor via e-mail. I also understand I may change the e-mail address
or rescind this permission at any time by contacting AZ Blue through AZ Blue.com.
City of Chandler
APPROVED AS TO FORM:
By:
By: ______________________________
Print Name: City Attorney
Title: _______________________________ ATTEST:
Date: ________________________________ By: ______________________________
City Clerk
Accepted and Agreed
BLUE CROSS AND BLUE SHIELD OF
ARIZONA, INC.
By:
Print Name:
Title: _______________________________
Date: ________________________________ Date Prepared 08.05.2026
Final 08.07.2026
REV: ASC_05.19.2026

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
Re: 2026 Form 5500 Schedule C Service Provider Information
Dear Sir or Madam:
Blue Cross Blue Shield of A is providing this information to you to support any
Form 5500 reporting obligations your group health plan has to the U.S. Department of Labor.
A. Blue Card Program
Under your contract with BCBSAZ, one of the benefits your employees and their dependents
("Participants") receive is access to healthcare services outside the geographic area BCBSAZ
serves under a program known as BlueCard. Typically, in that situation, Participants obtain care
from healthcare providers that have a contractual agreement with the local Blue Cross and/or Blue
Shield Licensee in that other geographic area (the "Host Blue"). Within that arrangement, BCBSAZ
is referred to as the "Home Blue."
Below is a list of indirect compensation that has been and/or is likely to be received in connection
with the BlueCard Program. Note that the fees and compensation subject to disclosure under the
Department of Labor rules include amounts that are not necessarily passed on to your ERISA Plan
or your Participants. The financial terms of the BlueCard Program passed on to your ERISA plan,
and additional details about the BlueCard Program, are described in your Administrative Services
Agreement with BCBSAZ.
1. BlueCard Access Fees: The Access Fee is charged by the Host Blue to us for making its
applicable provider network available to your members. The Access Fee will not apply to
nonparticipating provider claims. The Access Fee is charged on a per-claim basis and is
charged as a percentage of the discount/differential we receive from the applicable Host
Blue subject to a maximum of $2,000 per claim. When charged, we pass the Access Fee
directly on to you.
2. Administrative Expense Allowances (AEA): The AEA is a fixed per-claim dollar amount
charged by the Host Blue to us for administrative services the Host Blue provides in
processing claims for your members. The dollar amount is normally based on the type of
claim (e.g. institutional, professional, international, etc.) and can also be based on the size
of your group enrollment. When charged, we pass the AEA fee directly on to you.
Note: To be considered for reduced BlueCard PPO fees, the claim must be for an account
whose total Blue PPO enrollment exceeds 1,000 contracts
3. Use of Estimated or Average Pricing by Host Blues. As described in your administrative
service agreement, some Host Blues use estimated or average prices to determine the
negotiated price that is made available to BCBSAZ when plan participants access the Host
Blue's participating provider network. This may result in a difference (positive or negative)
between the price you pay on a specific claim and the actual amount paid to the provider
by the Host Blue.
The following describes the formulas used for determining an estimated or average price:
Estimated: A percentage is used to modify the claim price for covered services.
This percentage (either positive or negative) allows Host Blues to incorporate
adjustments and actuarial projections prospectively into the final price. The
percentage is determined by calculating the aggregate cost to the Host Blue over
a look-back period less any initial payments made to providers divided by the total
payments initially made to providers. The aggregate cost in the numerator includes
all provider retrospective settlements, anti-fraud and abuse recoveries, provider
refunds not applied on a claim-specific basis, performance-related bonuses or
For informational Purposes Only - NO Action Required

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
incentives, interest, other non-claim transactions and any positive or negative
balance in the variance account. The percentage is then actuarially adjusted for
anticipated changes in claims expenses for the prospective period. As of
December 31, 2025, the modifying percentage applied to claims from those Host
Blues that use estimated pricing ranged from (0.774%) to +3.50% the rate of
payment to the provider at the point of the claims. The modifying percentages
applied to claims from those Host Blues that will be used for estimated pricing have
not been calculated as of the date of this letter.
Average: An average price is determined for a defined category of provider (e.g.,
institutional, professional, etc.) of a Host Blue in a given geographic area. The
average is determined as follows:
Total amount paid to such providers over a look-back period, including
initial payments as well as applicable claim and non-claim related
transactions, which may include but are not limited to provider
retrospective settlements, anti-fraud and abuse recoveries, provider
refunds not applied on a claim-specific basis, performance-related
bonuses or incentives, interest, etc., and any positive or negative balance
in the variance account
divided by
Total amount of such providers' corresponding charges for covered
services over the same look-back period (claims for non-covered services
are not included in the calculation)
This result is an average price that is applied to each claim for the defined category
of provider of the Host Blue in the geographic area and presented as the negotiated
price.
The Host Blue determines whether it will use an actual, estimated or average price. The
use of estimated or average pricing may result in a difference (positive or negative)
between the price you pay on a specific claim and the amount the Host Blue pays to the
provider. However, the BlueCard Program requires that the amount paid by the member
and you is the final price; no future price adjustment will result in increases or decreases
to the pricing of past claims.
Any positive or negative differences in estimated or average pricing are accounted for
through variance accounts maintained by the Host Blue and are incorporated into future
claim prices. As a result, the amounts charged to you will be adjusted in a following year,
as necessary, to account for over-
Blue will not receive compensation from how the estimated price or average price
methods, described above, are calculated. Because all amounts paid are final, neither
positive variance account amounts (funds available to be paid in the following year), nor
negative variance amounts (the funds needed to be received in the following year), are
due to or from you. If you terminate, you will not receive a refund or charge from the
variance account.
Variance account balances are small amounts relative to the overall paid claims amounts
and will be liquidated or drawn down over time. The timeframe for their liquidation
depends on variables, including, but not limited to, overall volume/number of claims
processed and variance account balance. Variance account balances may earn interest
at the federal funds or similar rate. Host Blues may retain interest earned on funds held in
variance accounts.
For informational Purposes Only - NO Action Required

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
4. BlueCard Global Core Program. The BlueCard Global Core Program provides members
with access to an international network of inpatient, outpatient and professional providers.
The Blue Cross and Blue Shield Association (BCBSA) utilizes GeoBlue for Medical
Assistance and Claims support Services. The fees paid by the Home Blue are as
follows:
Medical Assistance Fee (in dollars)
General Inbound Calls $28.45 / Call
Provider Inquiry/Referral (non-medical situation) $22.35 / Call
Cashless access/Guarantee of Payment (GOP) $111.76 / GOP
Telephone Translation $63.50 / Call
Fulfillment $9.65 / Call
Provider/medical assistance information provided by a $96.52 / Call
nurse
Misrouted Calls $22.35 / Call
Medical Monitoring $294.64 / Case
Claims Support Services Fee (in dollars)
Claim preparation, processing and/or payment (includes $39.62 / Claim
translation, coding, currency conversion)
Misrouted claim (for example, domestic) $9.65 / Claim
Claim Status inquiry $22.35 / call/member ID
Medical records translation At Cost
Currency conversion gains/losses At Cost
Wire/ACH fees At Cost
Additional Services Fee (in dollars)
Medical Evacuation coordination $1,270.00 / Case
Medical Repatriation coordination $1,270.00 / Case
Repatriation of Remains coordination $609.60 / Case
Medical travel coordination $294.64 / Case
Assistance Partner Engagement (limited to ONLY Ranging from $100-500 per
countries where vendor is restricted from conducting Direct Pay Letter (DPL)
business)
Ad hoc UCR claim research, claim line-item audit and As agreed upon by Home Plan
case negotiation and GeoBlue
5. Negotiated Arrangements: With respect to one or more Host Plans, instead of using the
BlueCard Program, BCBSAZ may process your Participant claims for Covered Services
through Negotiated Arrangements.
Non-Standard negotiated AEA fees for 2025/2026:
Non-standard negotiated fees can range from either $5.48 to $17.28 per claim, or
$8.50 to $28.80 per contract per month depending on the negotiated arrangement
and/or the health plan product
For informational Purposes Only - NO Action Required

Docusign Envelope ID: 6EAB0C43-97B8-876D-828F-8F05751C6A78
B. Other Services
Under regulations related to the 2009 Form 5500 Schedule C - Service Provider Information,
BCBSAZ is required to provide information regarding certain indirect compensation paid by
BCBSAZ to other Service Providers during 2025 related to your contract with BCBSAZ.
Company Name: The Epoch Group, dba Clarity Performance Solutions
Address: 10740 Nall Ave., Suite 100 Overland Park, KS 66211
Service Provided: Claims Edit Resolution
Basis of Compensation: $1.78 per Claim Edit for low complexity, $2.65 for medium complexity, $3.76 for
high complexity, $5.35 for B2 adjustments, and $6.25 for Host EMR.
Company Name: Sutherland Global Services, Inc.
Address: 2 Brighton Rd., Suite 300 Clifton, NJ 07012
Service Provided: Data entry for provider data, assistance with credentialing
Basis of Compensation: $8.10 per provider recredentialing completed and $27.61 per initial credentialing
unit completed
Company Name: OptumRx.1
Address: 1600 McConnor Parkway, Schaumburg, IL 60173-6801
Service Provided: Pharmacy Claims Processing and select PBM services
Basis of Compensation: for electronic claims only
Pass-Thru Pricing Model = $0.75 per net paid claim
1 BCBSAZ paid compensation to OptumRx.only for groups who used BCBSAZ to manage their pharmacy
benefits.
Pharmacy Rebates BCBSAZ receives rebates from certain Pharmaceutical Manufacturers for certain
drugs. Subject to the terms of your BCBSAZ Administrative Services Agreement your Group may be eligible
for a Pharmacy Rebate. BCBSAZ may earn interest income on Pharmacy Rebates during the period after
the Rebate is paid to BCBSAZ and prior to payment to your Group.
If you have any questions, please contact your BCBSAZ Account Manager.
Sincerely,
For informational Purposes Only - NO Action Required