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Home My WebLink AboutC25-172 Cigna Administrative Services Aimee E. Burnham Contract Director Cigna Healthcare March 12, 2025 Eagle County Government, a Body Corporate and Politic 500 Broadway Eagle, CO 81631 RE: Administrative Services Only Account No. 3341075 Whom it May Concern: This letter will serve as an amendment to the Administrative Services Only Agreement between Cigna Health and Life Insurance Company (“CHLIC”) and Eagle County Government, a Body Corporate and Politic (“Employer”), effective January 1, 2018, (the “Agreement”) and as amended on January 1, 2020, January 1, 2021, January 1, 2022, January 1, 2023, June 1, 2023, and January 1, 2024. Effective as of January 1, 2025, the Agreement is hereby amended as set forth below. Any provision or subsection set forth in this amendment shall be deemed to: (a) replace in its entirety the same subsection in the current Agreement; and/or (b) add new provisions or subsections. Only those provisions and subsections set forth in this amendment are deemed amended or added, and all provisions and subsections not identified herein shall be deemed unaffected by this amendment and, accordingly, shall remain in full force and effect. Section 6, “Audit Rights,” of the Administrative Services Only Agreement is hereby amended in its entirety as follows: Section 6. Audit Rights a. Employer may audit CHLIC’s administration of Plan Benefits at no additional charge while this Agreement is in effect and in accordance with the following requirements: i. Notification and timing of audit. a. For a clinical audit, Employer shall provide to CHLIC a scope of audit letter, which scope shall be mutually agreed upon by the parties, and a fully executed audit agreement, together with a ninety (90) day advance written request to audit. b. For all other audits described below, Employer shall provide to CHLIC a scope of audit letter, and a fully executed audit agreement, together with a forty -five (45) day advance written request for audit. ii. Employer may designate with CHLIC's consent (which consent shall not to be unreasonably withheld) an independent, third-party auditor to conduct the audit (the "Auditor"). iii. Employer and CHLIC will agree upon the date for the audit during regular business hours in a virtual/remote audit environment or at CHLIC's office(s), as business needs require. iv. Except as otherwise agreed to by the parties in writing prior to the commencement of the audit, the audit shall be conducted in accordance with the terms of CHLIC's audit agreements which shall be signed by the Auditor prior to the start of the audit. Routing W122A 900 Cottage Grove Road Hartford, CT 06152 Telephone 860.226.4422 Aimee.Burnham@evernorth.com Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Eagle County Government, a Body Corporate and Politic March 12, 2025 Page 2 v. If the audit identifies any errors requiring adjustments, such adjustments will be made in accordance with this Agreement and based upon the actual claims and fees reviewed and not upon statistical projections or extrapolations. vi. Employer shall be responsible for its Auditor’s costs. In the event Employer requests to alter the scope of the audit, CHLIC will endeavor to reasonably accommodate the Employer’s request, which may be subject to additional charges to be mutually agreed upon by the Employer and CHLIC prior to the start of the audit. vii. If Employer has five thousand (5,000) or more employees who are Members, Employer may conduct one such audit every Plan Year (but not within six (6) months of a prior audit); otherwise, Employer may conduct one such audit every two (2) Plan Years (but not within eighteen (18) months of a prior audit). viii. In no event shall any audit involve Plan benefit payments or administration prior to the most recent two (2) plan years, (unless otherwise noted) or involve Plan benefit payment or administration that has been previously audited. ix. New audits shall not be initiated until all parties have agreed that the prior audit is closed. x. Employer may (as determined by CHLIC based upon the resources required by the audit requested) be responsible for CHLIC's reasonable costs with respect to the audit, except that while this Agreement is in effect there shall be no additional cost to Employer for an audit of the following: ● Claims: Payment documents relating to a random, statistically valid sample of two -hundred twenty- five (225) claims paid. ❍ Requests to review provider contracts will be subject to CHLIC’s current criteria and contrary terms in Participating Provider Agreements. ● Appeals: Documents, including payment documents as appropriate, relating to a random sample of up to thirty-five (35) appeals. ● Customer Service: Documentation and review of call recordings relating to a random sample of up to thirty-five (35) Member calls. ❍ CHLIC maintains call recordings for up to twelve (12) months, and any customer service audit is limited to the availability of the call recordings. ● Accumulator/Combined Deductible: Audits are allowed based on mutually agreed-upon scope of up to thirty (30) cases. ● Benefit Implementation: Audits are allowed based on mutually agreed-upon scope and timing. CHLIC will support the benefit implementation audits for review of benefit set up related to claim processing. ● Medical Cost Containment Program Fees (MCCP) (Out -of-Network Protection and Payment Integrity Program Fees): MCCP audits are limited to confirmation of fees paid by the Employer related to the programs in place. The audits will not include review of documentation that is not applicable to claim administration. In addition, Auditor will need to agree that it will not outreach to Participating Providers or Members for claim or medical record information. MCCP fee audits are based on the following criteria: Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Eagle County Government, a Body Corporate and Politic March 12, 2025 Page 3 ❍ Random samples based on the following: ■ Twenty-five (25) claims in which fees were paid for Medical Out-of-Network Protection Programs which include Network Savings Program and Bill Negotiation Services (Pre- payment Cost Containment for Non-contracted claims) ■ One-hundred (100) claims in which fees were paid related to Payment Integrity Programs which include Medical Bill Review; Medical Implant Device Review; Clinical Waste and Abuse Claim Review; High-Cost Specialty Pharmaceutical Review; other target billing accuracy review programs; Diagnosis Related Grouping Review; Coordination of Benefits (COB) Investigation and Recoveries; Secondary Vendor Recovery Program; Provider Credit Balance Recovery Program; Eligibility Overpayment Recovery Vendor Services; and Subrogation/Conditional Claim Payment. ● Clinical Cases/Calls: Subject to CHLIC staff availability, the standard annual allowable number of cases/calls for audit and standard number of days allowed to conduct the audit is as follows, based on number of Employer Subscribers during the time period covered by the audit: Number of Subscribers # Cases # Calls # Days* 5,000 & under 10 3 1 >5,000 & < 25,000 15 4 1 >25,000 & < 75,000 20 5 1.5 >75,000 25 6 2 All cases and calls related to case selection will be prepared and presented in compliance with all Applicable Laws, Privacy Addendum in Exhibit D, including but not limited to the HIPAA Privacy and Security Rules and 42 C.F.R. Part 2.. Cases selected will have been managed during the rolling twelve (12) month period prior to the date of the written request to conduct an audit and not previously audited for the current audit scope. *Takes into consideration length of time to complete the standard number of cases and calls based on a one (1) year lookback scope period. Section 7.c of the Administrative Services Only Agreement is hereby amended in its entirety as follows: Alternative Litigation Management Option. Contingent upon timely payment by Employer of the associated additional “Alternative Litigation Management Option” charge set forth in the Schedule of Financial Charges, Employer may elect to have CHLIC assume responsibility for the management of any legal actions with respect to disputed claims for Plan Benefits and bear the legal expenses associated with defending such action so long as CHLIC processed the claim(s) in dispute. Each Party will provide notice to the other of any such legal action and will fully cooperate in the defense of the action. Nothing in this paragraph c shall be read to contradict the explicit terms of 7.a and 7.b. Employer shall remain solely responsible for payment of any Plan benefits determined to be payable under the Plan as a result of a legal action and any damages or penalties assessed in connection with such legal action. This Alternative Litigation Management Option does not extend to (i) legal actions against Employer and/or CHLIC related to the payment of Extra-Contractual Benefits; or (ii) legal actions in which a conflict of interest exists or arises between Employer and CHLIC. Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Eagle County Government, a Body Corporate and Politic March 12, 2025 Page 4 Section 22, “Independent Contractors,” of the Administrative Services Only Agreement is hereby amended in its entirety as follows: Section 22. Independent Contractors Except as explicitly set forth in this Agreement, the Parties’ relationship with respect to each other is that of independent contractors and nothing in this Agreement is intended, and nothing shall be construed to, create an employer/employee, partnership, principal-agent, or joint venture relationship, or to exercise control or direction over the manner or method by which CHLIC performs services hereunder. No Party shall make any statement or take any action that might cause a third party to believe such Party has the authority to transact any business, enter into any agreement, or in any way bind or make any commitment on behalf of the other Party, unless set forth in this Agreement or expressly authorized in writing by a duly authorized officer of the other Party. For the avoidance of doubt, CHLIC authorized to perform certain services on behalf of Employer under this Agreement and this provision is not intended to in any way diminish that authorization. The "Schedule of Financial Charges" and "Exhibit B", “Services” are hereby deleted in their entirety and replaced with the "Schedule of Financial Charges" and "Exhibit B, “Services,” as attached hereto. Exhibit C, "Audit Agreement (Sample),” of the Administrative Services Only Agreement is hereby deleted in its entirety and left intentionally blank. Exhibit C1, “Clinical Audit Agreement (Sample),” of the Administrative Services Only Agreement is hereby deleted in its entirety. Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Eagle County Government, a Body Corporate and Politic March 12, 2025 Page 5 The terms of the Administrative Services Only Agreement identified above, as mentioned herein, will be effective as of January 1, 2025. Please indicate your agreement to the amendment by signing the enclosed copy of this letter where indicated and returning it to me. Alternatively, this amendment shall become effective on the effective date indicated unless Employer notifies CHLIC either electronically or in writing (at the address indicated above) within sixty (60) days of the date of this letter that it does not accept all the terms of this amendment notwithstanding any provision to the contrary in the Administrative Services Only Agreement. In that case, CHLIC shall cooperate to negotiate mutually agreeable terms with Employer. Once agreement with respect to the terms of the amendment is reached, the amendment will apply retroactively to the effective date. Sincerely, Printed Name: Aimee E. Burnham Title: Its Contract Director Duly Authorized Cigna Health and Life Insurance Company Accepted by: EAGLE COUNTY GOVERNMENT, A BODY CORPORATE AND POLITIC By: ________________________________________ Printed Name: ________________________________________ Title: Its _________________________________________ Executed this ____ day of ________, in the year ________ Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 May County Manager 1st 2025 Jeff Shroll Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 6 03/12/2025 Schedule of Financial Charges Certain fees and charges identified in this Schedule of Financial Charges will be billed to Employer monthly in accordance with CHLIC's then standard billing practices. However, CHLIC is authorized to pay all fees and charges from the Bank Account unless otherwise specified in this Agreement. MEDICAL ADMINISTRATION CHARGES Product Description Charge Medical Open Access Plus (OAP) with Care Management Preferred $68.12/employee/month MEDICAL NETWORK ACCESS FEE, UTILIZATION MANAGEMENT FEE AND OPTIONAL PROGRAM FEE Product Description Charge Medical OAP Access Fee $29.71/employee/month Included in Medical Administration Charge AMOUNTS OWED TO CHLIC CHLIC may pay amounts with its own funds on behalf of Employer or the Plan for charges which Employer or the Plan is obligate d to pay under the Agreement including Plan Benefits, Bank Account Payments (including fixed per person payments and pay -for-performance payments to Participating Providers), governmental taxes or assessments and those amounts paid by CHLIC shall be the Employer’s financial responsibility. CHLIC is authorized to recover all such amounts from the Bank Account. CIGNA HOME DELIVERY PHARMACY DISCLOSURE Product Charge Cigna Home Delivery Pharmacy (a CHLIC affiliated company(ies)) Specialty drugs dispensed by Cigna Home Delivery Pharmacy and administered under the Plan’s medical benefit. “Cigna Home Delivery Pharmacy” means a duly licensed pharmacy operated by CHLIC or its affiliates, where prescriptions are filled and delivered via the mail service. Cigna Home Delivery Pharmacy may maintain product purchase discount arrangements and/or fee-for- service arrangements with pharmaceutical manufacturers and wholesale distributors. Cigna Home Delivery Pharmacy contracts for these arrangements on its own account in support of its pharmacy operations. These arrangements relate to services provided outside of this The drug's charge under a national specialty drug discount schedule that generates a 20.50% annual average aggregate discount off AWP across specialty drug claims dispensed at Cigna Home Delivery Pharmacy to Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 7 03/12/2025 Agreement and other pharmacy benefit management arrangements and may be entered into without regard to whether a specific drug is on one of the formularies that CHLIC offers to entities like Employer that sponsor group health plans. Discounts and fee-for-service payments received by Cigna Home Delivery Pharmacy are not part of the administrative fees or other charges paid to CHLIC in connection with CHLIC's services hereunder. This provision shall survive termination or expiration of the Agreement. CHLIC's self-funded and insured group-client book of business. FEES FOR PROCESSING RUN-OUT CLAIMS OAP Run-Out Period of twelve (12) months No Additional Cost CHLIC MEDICAL OUT-OF-NETWORK PROTECTION PROGRAM FEES Employer agrees that CHLIC will use the programs listed in this section (the “Out-of-Network Protection Programs” or “OON Protection Programs”) to contain costs with respect to charges for health care services/supplies that are covered by the Plan, as set fo rth in the applicable Plan Booklet. These services and supplies may include, but are not limited to, claims received from Non -Participating Providers and claims that are subject to the federal No Surprises Act and are not otherwise subject to state law (“NSA Services”). OON Prote ction Programs may also apply to covered services received from providers that are not included in certain specialized networks but who are otherwise Particip ating Providers in CHLIC’s broader networks (for example, OAP Participating Providers that are not included in specialized networks designed for gene therapy or advanced cell therapy). CHLIC may contract with vendors to provide or perform various services related to the OON Protection Programs. These vendors may charge for the services they provide in administering the OON Protection Programs (“Vendor Charges”). CHLIC’s charges for administering the OON Protection Programs (“OON Protection Program Charges”) are set forth in the tables below and are calculated for each claim based on the applicable percentage of the: 1) “Gross Savings” (i.e., the difference between the charge the provider made or would have made, and the allowable amount resul ting from the OON Protection Programs); or 2) “Net Savings” (i.e., the Gross Savings less the applicable Vendor Charge). OON Protection Program Charges, plus any per claim Vendor Charge, shall not exceed $30,000 per claim (the “Per Claim Cap”). V endor Charges generally range from 5-11% of Gross Savings but may change from time to time. CHLIC will make a per claim charge to the Bank Account that includes both CHLIC’s applicable OON Protection Program Charges, as shown in the tables below, and the applicable Vendor Charge. CHLIC will pay the vendor its charge. OON Protection Program Charges will appear in Employer’s Bank Account activity data reports. The administration of the OON Protection Programs is consistent with the claim administration practices with respect to CHLIC 's own health care Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 8 03/12/2025 insurance business, unless otherwise required by law. A. OON Protection Programs for Services/Supplies that are not NSA Services OON Protection Programs seek to reduce providers’ charges to amounts that CHLIC, in its discretion, determines are market com petitive (“Discounts”). CHLIC, or a vendor retained by CHLIC, may attempt to obtain Discounts through accessing a provider’s agreement with a third party or negotiating the provider’s charges. Negotiations may include (i) CHLIC, or a vendor retained by CHLIC, entering into an agreement with the provider that establishes the amount at which the provider is willing to accept as payment in full; or (ii) using repricing programs through which CHLIC, or a vendor retained by CHLIC, determines the allowed amount based on a rate deemed to be market competitive and the p rovider does not bill the patient and/or obligate the patient to pay the difference between the charged amount and the allowed amount. In many cases, applying Discounts may substantially reduce the total cost of the claim and/or the patient’s out -of-pocket cost and avoid the patient being balance-billed for amounts the Plan does not cover, but may result in higher payments than the Employer’s applicable (a) Plan-/policyholder- selected percentile of provider charges for the same or similar service or supply in the geographic area based on a database selected by CHLIC, or (b) Plan-/policyholder-elected percentage of a fee schedule that CHLIC has developed based on a methodology similar to a methodology used by Medicare to determine the allowable reimbursement for the same or similar service within the geographic market. Discounts may be determined on a claim-by-claim basis before or after services are rendered. If no Discount is applied through OON Protection Programs, reimbursement will be based on the terms of the benefit Plan. 1. Network Savings Program 29% of net savings 2. Bill Negotiation Services Programs (Inpatient, outpatient, physician/professional) ● Supplemental Network 29% of net savings ● Professional Fee Negotiation 29% of net savings ● Line-Item Analysis Re-pricing (outpatient, physician/professional) 29% of net savings ● Line-Item Analysis Re-pricing (inpatient hospital) Gross savings up to 5% of the hospital bill 3. Negotiation or independent dispute resolution under state laws, if applicable, addressing reimbursement to Non-Participating Providers, where payment is not based on the Network Savings Program or Bill Negotiation Services Programs. If additional payment is owed as a result of negotiations or independent dispute resolution under state law, CHLIC, as agent for 29% of net savings Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 9 03/12/2025 the Employer, shall make Bank Account Payments from the Bank Account in the amount of such additional payment. (There are no additional fees charged to the Employer for handling the independent dispute resolution process.) B. OON Protection Programs for NSA Services For NSA Services, CHLIC will issue initial payments at amounts determined by CHLIC or its vendors (“Initial Allowed Amount”). The Initial Allowed Amount may be based on Discounts and may be higher than, equal to, or lower than the recognized amount or qualifying payment amount (QPA), as calculated by CHLIC. Patient cost-share will be based on the lower of the QPA, the non-Participating Provider’s billed charges, the amount determined by CHLIC to be required by state law (if applicable), or the Initial Allowed Amount. Patient cost -share will not increase as a result of negotiations or independent dispute resolution determinations under the No Surprises Act. If additional payment abo ve the Initial Allowed Amount is owed as a result of negotiations or independent dispute resolution under the No Surprises Act, CHLIC, as agent for the Employer, shall make Bank Account Payments from the Bank Account in the amount of such additional payment. 1. Network Savings Program 29% of net savings 2. Bill Negotiation Services Programs (Inpatient, outpatient, physician/professional) ● Supplemental Network 29% of net savings ● Professional Fee Negotiation 29% of net savings ● Line-Item Analysis Re-pricing (outpatient, physician/professional) 29% of net savings ● Line-Item Analysis Re-pricing (inpatient hospital) Gross savings up to 5% of the hospital bill 3. Negotiation or independent dispute resolution under the federal No Surprises Act, where payment is not based on the Network Savings Program or Bill Negotiation Services Programs. If additional payment is owed as a result of negotiations or independent dispute resolution, CHLIC, as agent for the Employer, shall make Bank Account Payments from the Bank Account in the amount of such additional payment. (There are no additional fees charged to the Employer for handling the independent dispute resolution.) 29% of net savings CHLIC MEDICAL PAYMENT INTEGRITY PROGRAM FEES CHLIC administers the programs listed below to contain costs with respect to charges for non-Participating and Participating medical health care service/supplies that are covered by the Plan (the “Payment Integrity Programs”). In administering these Payment Integrity Programs, CHLIC Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 10 03/12/2025 may contract with vendors to perform various tasks related to the Payment Integrity Programs. CHLIC’s charge for administering the Payment Integrity Program is the applicable percentage indicated in the table below of t he: 1 “Gross Savings” (i.e., the difference between the originally calculated allowable and the amount paid to the provider as a re sult of the Payment Integrity Program); and 2 “Gross Recovery” (i.e., the amount recovered as a result of the Payment Integrity Program). CHLIC will make a per claim charge to the Bank Account that includes both CHLIC’s applicable Payment Integrity Program charge , as shown in the table below, and the applicable vendor charge. CHLIC will pay the vendor its charge. Payment Integrity Program charges will appear in Employer’s Bank Account activity data reports. 1. Bill Review, Clinical coding validation and editing (Pre- and Post-payment) Includes: ● Hospital Bill Review (Inpatient/Outpatient) ● Medical Implant Device Review (Inpatient/Outpatient) ● Clinical Waste and Abuse Claim Review (Facility & Professional) ● High-Cost Specialty Pharmaceutical Review ● Other Target Billing Accuracy Programs If there is savings or recovery, any fees or expenses passed through by the hospital or regulatory agency, plus 29% of the gross savings/gross recovery 2. Diagnosis Related Grouping (DRG) Review (Pre- and Post-payment) to ensure coding is consistent with care rendered and coding standards. If there is savings or recovery, any fees or expenses passed through by the hospital or regulatory agency, plus 29% of the gross savings/gross recovery 3. Coordination of Benefits (COB) Investigation and Recoveries to identify if Member has other insurance. Includes Medicare and other commercial health coverage. 29% of the gross recovery 4. Secondary Vendor Recovery Program. Specialized vendor partners run proprietary queries to determine the reasonableness, appropriateness, accuracy, and applicability of select claim 29% of the gross Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 11 03/12/2025 payments recovery 5. Provider Credit Balance Recovery Program. Audit/reconciliation of facility accounts which are in a negative balance, due to incorrect billing or payment made to a provider. 29% of the gross recovery 6. Eligibility Overpayment Recovery Vendor Services. Identification and recovery of funds in situations where the overpayment is due to the late receipt of Member termination information. 29% of the gross recovery 7. Subrogation/Conditional Claim Payment. Identification, investigation, and recovery of claim payments involving other party liability or where another entity is responsible for payment (including by way of example but not by limitation automobile insurance, homeowner insurance, commercial property insurance, worker’s compensation). 29% of the gross recovery if no counsel is retained and in all other instances, including cases where state law requires that employee benefit plans be named as party defendants or involuntary plaintiffs. Litigation costs if counsel is retained and an appearance is filed on behalf of CHLIC or Employer in any litigation, or a lawsuit is filed on their behalf, plus 5% of the gross recovery. 8. Medical Cost Class Action Recoveries. CHLIC identifies, monitors, and may (but is not required to) participate, on behalf of Employer, as a plaintiff in class action lawsuits or similar legal proceedings against third parties whose actions entitle Employer to recover damages for medical costs it paid as Plan Benefits (e.g. medical device product liability class actions, mass tort recovery class actions, etc.), including, without limitation, lawsuits alleging legal or 35% of the gross recovery Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 12 03/12/2025 equitable claims like product liability, fraud, anti-trust violations, or unfair trade practices. As part of this authority, CHLIC may participate in a settlement, exclude Employer from a settlement and/or otherwise represent Employer’s interests outside the settlement. CHLIC collects and retains a percentage any recovery (net of attorneys’ fees) attributable to Employer’s Plan as compensation for these services. ADVANCED CELLULAR THERAPY PROGRAM Advanced Cellular Therapy Program The Advanced Cellular Therapy Program (ACT) is an enhanced network benefit solution designed to manage the high cost of advanced cellular therapies (e.g. CAR T-cell therapy). This program delivers predictability, clinically appropriate care and maximizes affordability by leveraging a specially selected provider network, with benefit language that includes a travel benefit and a dedicated care management team to support Participating Members receiving these therapies. For all in-network medical claims covered under the ACT Program at an existing ACT participating provider, Employer shall pay CHLIC (who in turn will pay the rendering ACT participating provider) a Guaranteed Price for the covered advanced cellular therapy. The Guaranteed Price shall equal the Average Wholesale Price (AWP) of the covered advanced cellular therapy minus 10% and will be charged to the Bank Account. Guaranteed Price for the covered advanced cellular therapy (ACT) AWP minus 10% For purposes of the ACT Program, “Average Wholesale Price” or “AWP” shall mean the average wholesale price of a covered drug as established and reported by Medi-Span. The applied AWP of a covered drug shall be the AWP for the actual eleven (11) digit National Drug Code (“NDC”), at the time that the covered drug is adjudicated. Notwithstanding any other provision in this Agreement, in the event of any major change in market conditions affecting the pharmaceutical or pharmacy benefit management market or if CHLIC decides to replace AWP as its pricing benchmark with an alternative benchmark and/or replace Medi-Span, or other such publication, as its source for the AWP, or alternative benchmark with a different pricing source, CHLIC may adjust the Guaranteed Price as it reasonably deems necessary to preserve the economic value or benefit of the Guaranteed Price to CHLIC as it existed immediately prior to such change. Employer understands and agrees that the amount paid by CHLIC for the therapy may or may Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 13 03/12/2025 not be equal to the Guaranteed Price charged to Employer and CHLIC will absorb or retain any difference. There are related costs for Participating Members receiving these therapies that will be paid as covered services according to the Plan. CARE MANAGEMENT/COST CONTAINMENT PROGRAM FEES CHLIC arranges for third parties to provide care management services to: (i) contain the cost of specified health care services/items overall with respect to all plans insured and/or administered by CHLIC, and/or (ii) improve adherence to evidence based guidelines designed to promote patient safety and efficient patient care. Unless otherwise specified in this Schedule of Financial Charges, charges for these services will be processed through the Bank Account. Applicable third- party fees and care management program services are listed below, and additional details are available upon request. Medical Management (inclusive of Medical Necessity Review) of Chiropractic services. National Average is $0.16 PMPM; rates vary by market and are available upon request. In addition to such third parties, CHLIC has arranged for an affiliate, eviCore, to provide the following care management/cost-containment programs: Pre-certification of coverage of radiation therapy services. $958.00 per episode of care (EOC) Pre-certification of coverage of diagnostic cardiology services. $0.19 PMPM Pre-certification of coverage of medical oncology services. $1,136.00 per episode of care (EOC) Oncology Consult Service. Medical oncology cases submitted for prior authorization will be subject to additional review against certain clinical criteria, including the appropriate setting of care/service, to determine if the case would benefit from a physician -to-physician consult $4,250.00 per completed consultation Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 14 03/12/2025 focused on the accuracy of the diagnosis and the optimal treatment plan. eviCore will engage a third party to facilitate the consultation, which will occur only upon acceptance by physician and the consent of the Participant. (Billed directly to Employer) Pre-certification of coverage of musculoskeletal therapy services. $0.42 PMPM Services related to the coverage of high-tech radiology which may include pre-certification. In certain instances, the Plan will pay eviCore a fee on a per member/per month basis for pre-certification, arranging care, and other services that eviCore may render. Such reimbursement will be in addition to the amount that the Plan pays to reimburse the provider through which eviCore arranged for the provision of the service or supply, which will be based on eviCore’s contracted rate with that provider. In such instances, Plan Benefits and member cost-share will be determined based on the rate that eviCore contracted to pay the provider for the provision of the service or supply. eviCore may also charge for services related to the provision of high-tech radiology as described below in “Other Vendors and Health Care Services Providers.” Fee reimbursement method and rates may vary by market and are available upon request. Pre-certification of coverage of gastroenterology services. $0.12 PMPM Pre-certification of coverage for appropriate setting of care/service for high-tech radiology services $0.17 PMPM Pre-certification of coverage for appropriate setting of care/service for certain medical oncology drugs (redirection may be to Accredo, a CHLIC affiliate). 30.00% of shared savings (where savings is derived from the difference between drug dose cost at higher cost provider initially requested and drug dose cost at lower cost Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 15 03/12/2025 provider). Fee shall not exceed $5,000.00 per dose for a maximum of three doses resulting in a maximum total of $15,000.00. Note: CHLIC may retain a portion of the shared savings fee before reimbursing eviCore. Pre-certification of coverage of sleep management services. $0.13 PMPM Network management and care coordination of coverage of home health, durable medical equipment and home infusion services. $0.32 PMPM CHLIC may revise charges/fees by giving Employer at least sixty (60) days’ prior written notice. EXTERNAL REVIEW AND CONSULTATIVE REVIEW FEES When a Member elects an External Review (as that term is defined in the Patient Protection and Affordable Care Act (PPACA)) of a benefit determination by an independent third party, the cost of a specific third party review is dependent on the nature and complexity of the issue on appeal. Third party review charges will be commensurate with the level of expertise necessary and the time required to complete the review. $500-$1,500 Per Review STRATEGIC ALLIANCES CHLIC contracts directly or indirectly with other managed care entities and third party network vendors for access to their provider networks and discounts. These third parties charge a network access fee, which is included in CHLIC's monthly charges, as a result of the application of their discounts. Additional details regarding specific charges will be provided upon request. All Medical Products OTHER VENDORS AND HEALTH CARE SERVICES PROVIDERS The fixed per person per period and/or fee-for-service charges that CHLIC has directly or indirectly negotiated with Participating Providers for in-network health care services and/or All Products Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 16 03/12/2025 supplies will be charged to the Bank Account and will be used in calculating any applicable Member cost-sharing. In addition, performance-based payments to Participating Providers will be charged to the Bank Account. Such payments will be at the payment rates then in effect, which may be amended from time to time. CHLICwill charge a fee equal to a percent of performance-based payments, which will be added to these payments to support incremental costs associated with administering the programs. Additional reporting available upon request. For certain types of specialty care, including, but not limited to, home health care, durable medical equipment, sleep management, high tech radiology, chiropractic care, acupuncture, physical medicine (such as physical and occupational therapy), speech therapy, orthotics and prosthetics, implants, and hearing, in certain markets CHLIC may contract with various third parties and/or affiliated companies, including eviCore, (“Specialty Vendors”) to arrange for the provision of care through their own networks of health care providers on a fee-for-service basis. In addition to arranging for care through their own networks of providers, these Specialty Vendors may also provide additional services, including utilization management services and case management services designed to (i) improve adherence to coverage guidelines; and (ii) contain overall healthcare costs to the Plan. Specialty Vendors are included within the definition of “Participating Provider” set forth in this Agreement and in any benefit booklet covering the Plan. When care is arranged through a Specialty Vendor’s network of providers, the form of reimbursement to the Specialty Vendor will be through one of the following methods: ● Fee-For-Service Payment: In certain instances, the Plan will pay the Specialty Vendor rather than the treating provider on a fee-for-service basis as a claim for Plan Benefits. The Specialty Vendors’ fee-for-service charges may be higher than the amounts that the Specialty Vendor contracts to pay the provider for the provision of any particular service or supply, and some portion of the Specialty Vendor’s charges may be attributable to the services that the Specialty Vendor provides in addition to those services or supplies provided by the Specialty Vendor’s network of providers, including any utilization management services and case management services. In such instances, Plan Benefits and member cost-share will be determined based on the Specialty Vendor’s charges according to Plan terms. Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 17 03/12/2025 ● Administration Capitation Payment: In certain instances, the Plan will pay the Specialty Vendor a fee on a per member/per month basis for arranging care and other services that the Specialty Vendor may render. Such reimbursement will be in addition to the amount that the Plan pays to reimburse the provider through which the Specialty Vendor arranged for the provision of the service or supply, which will be based on the Specialty Vendor’s contracted rate with that provider. In such instances, Plan Benefits and member cost-share will be determined based on the rate that the Specialty Vendor contracted to pay the provider for the provision of the service or supply. ● All-Inclusive Capitation Payment: In certain instances, the Plan will pay the Specialty Vendor a fee on a per member/per month basis that covers (i) the services that the Specialty Vendor may render, including arranging care, and (ii) the fees charged by the provider through which the Specialty Vendor arranged for the provision of the service or supply. In such instances, Plan Benefits and member cost-share will be determined based on the rate that the Specialty Vendor contracted to pay the provider for the provision of the service or supply. CHLIC’s arrangements with Specialty Vendors are subject to change at any time, and upon request, additional information can be provided that identifies current Specialty Vendors, their area of specialty(ies), whether they are CHLIC affiliates, and the form of payment that they currently receive. NOTICE REGARDING PAYMENTS FROM THIRD PARTIES Rebate and Other Remuneration Disclosure (Medical) CHLIC may directly or indirectly receive and retain payments under contracts with pharmaceutical manufacturers or third parties with respect to Members' utilization of the manufacturer’s products covered under the Employer's Plan medical benefit. These payments may include rebates, service fees (e.g. administrative fees), or other remuneration. CHLIC directly or indirectly contracts with pharmaceutical manufacturers or other third parties for any remuneration on its own behalf, based on its book of business, and for its own benefit, and not on behalf of Employer or the Plan. Accordingly, CHLIC retains all right, title and interest to any and all such remuneration received from manufacturer; neither Employer, its Members, nor Employer's Plan retains any beneficial or proprietary interest in any such remuneration, which shall be considered part of the general assets of CHLIC. This provision shall survive termination or expiration of the Agreement. All Medical Products Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 18 03/12/2025 Implementation/Referral Fee Disclosure From time to time, CHLIC, directly or through its affiliates, arranges with third parties (e.g., service vendors, provider network managers) to provide various services (e.g., cost - containment services or health care services) in connection with the Plan. CHLIC and its affiliates may receive payments from such third parties to help defray CHLIC's expenses associated with its implementation and/or ongoing administration of these arrangements or as a reimbursement for services or network access provided to such parties by CHLIC. CHLIC may also receive compensation from third-party vendors that Employer may retain based upon a referral from CHLIC or that Members may utilize following an introduction facilitated by CHLIC or an affiliate. CHLIC may also receive: ● network administration fees from some providers participating in its provider network, ● credits from banks on balances in accounts utilized to administer claims, ● non-material incidental compensation/benefits from other source as a result of administering the Plan. All Products SBC COMPLIANCE ASSISTANCE CHLIC shall provide the following services to assist Employer in meeting its compliance obligations under section 2715 of the Public Health Service Act as added by the Patient Protection and Affordable Care Act and applicable regulations with respect to the provision of the Summary of Benefits and Coverage (“SBC”), translation notice and glossary. Applicable to all medical plans including HRA and FSA which are considered "group health plans" subject to the SBC requirements. 1. Preparation of SBC, translation notices. CHLIC will not be responsible for any changes that Employer makes to the SBC. No charge 2. Provide SBC, translation notices prepared by CHLIC to Employer electronically as well as any updates or material modifications. No charge 3. Include in SBC a summary of benefits administered by carve-out vendor if Employer or carve-out vendor provides CHLIC with necessary carve-out benefit information at least twelve (12) weeks prior to the date the SBCs are to be delivered to Employer. $500 for each benefit option under the Plan for which carve-out vendor benefits are included in SBC Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 19 03/12/2025 ADDITIONAL SERVICES Service Description Charge Third Party Individual Stop Loss Interface Fee CHLIC will provide its standard individual stop loss third party reporting package only after the stop loss carrier and Employer have executed CHLIC’s standard Non-Disclosure/Data Sharing Authorization Agreements. CHLIC’s standard individual stop loss reporting package is based on paid claim data only (documentation and information, including but not limited to, incurred-but-not-paid claims, projected claims, pre-certifications of coverage, case management records and notes, course of treatment or prognosis, and internal audits will not be provided). Employer should be aware that third party stop loss coverage may result in a difference of reimbursable claims under the stop loss carrier’s policy versus payable covered services under the medical benefit plan. For OAP Products: $3.75/employee/month Included in Medical Administration Charge Behavioral Health Access to inpatient and outpatient behavioral health services and focused utilization review and case management for both inpatient and outpatient, in-network behavioral health services. For OAP Products: Included in Medical Access Fee (All Members) Comprehensive Oncology Program The Cigna Cancer Support Program - A program designed to deliver comprehensive oncology support targeting Members through all stages of cancer; from those newly diagnosed, in post cancer care, in active treatment and with or without complications and/or end of life status. The program addresses cancer prevention through education; providing assistance to Members in active treatment, utilizing evidence based clinical resources, development of survivorship plans for cancer survivors, and supporting Members and their families with end-of-life decisions if appropriate. For OAP Products: Included in Medical Access Fee Specialty Medication Support A targeted condition medication therapy management program in which CHLIC provides support for Members using specialty medications for certain chronic conditions and that are obtained or administered at retail pharmacies or outpatient, office or home health care settings. As part of the program, Members are assisted with any questions they may have around medication side effects, given explanation around their Plan benefits, informed of the importance of adherence, assist with the prior authorization renewal coordination, assist with referrals to CHLIC Integrated Pharmacy Solutions clinicians and referrals to other Cigna coaching programs. CHLIC acts as the primary point of contact for Members enrolled in specialty condition counseling and works to ensure that Member needs are coordinated and referred appropriately. CHLIC conducts standardized assessments of Members to identify potential clinical issues and works in conjunction with nurses, pharmacists, and other parties to resolve. For the sake of clarity, if a specialty pharmacy affiliate of CHLIC provides therapy For OAP Products: Included at No Additional Cost Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 20 03/12/2025 management for specialty medications the pharmacy dispenses to Members, then it does so in its capacity as a specialty pharmacy and not on behalf of CHLIC; CHLIC does not exert direction or control over the pharmacists at any specialty pharmacy affiliate. Your Health First A proactive health education and improvement program for Members with a chronic condition. The program involves services that span across the Member's health needs. Behavioral coaching principles and evidence based medicine guidelines are utilized to optimize self-management skills and foster sustained health improvements. The program targets a chronic population at high risk for near term and future high cost medical expenses. Members are identified as having a chronic condition through a variety of sources which may include: claims data, referrals, and self-identification. A variety of resources is provided to those with a chronic condition, including access to online tools, personalized support, and targeted materials. The program includes the following components for those with a chronic condition: ● Chronic condition-specific coaching ● Pre- and post-discharge calls ● Lifestyle management coaching: stress, weight management and tobacco cessation ● Treatment decision support and coaching For OAP Products: Included in Medical Access Fee Alternative Litigation Management Option Claim litigation services pursuant to the Alternative Litigation Management Option as set forth in the Agreement. $3,500.00 Flat Annual Amount Claim and Appeals CHLIC will administer an optional second level of claim appeals as set forth in the Agreement. Included in Medical Administration Charge Cigna One Guide® The Cigna One Guide® advocacy solution utilizes a multimodal approach to support members and help them successfully navigate the health care system. members are serviced by personal guides that include frontline service staff, as well as clinicians and non -clinician support staff from our medical, behavioral and pharmacy programs. In addition to connecting with personal guides via telephone, members can also interact with personal guides via the click-to-chat feature on myCigna.com (web and app), enabling For OAP Products: $3.50/employee/month Included in Medical Access Fee Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 21 03/12/2025 members to engage with CHLIC and One Guide in the way in which they prefer. One Guide helps simplify and strengthen the connection between members, their benefit plan, and their overall health and well-being. Through personalized and relevant messaging, One Guide proactively engages members with clear ways to save money, stay healthy, and improve health outcomes that lead to a healthy lifestyle. One Guide offers: ● education on health plan features, account balances and ways to maximize benefits and earn available incentives ● guidance in finding the right doctor, lab, convenience care or pharmacy ● immediate connection to health coaches and other resources The goal of One Guide is to help Members take care of what matters most - staying healthy, saving money, and improving health. Pharmacy Integration For OAP Products: $0.50/employee/month Included in Medical Access Fee Transparency in Coverage and Consolidated Appropriations Act, 2021 CHLIC will make available an internet-based self-service tool for use by Members, as well as certain data in machine-readable file format on a public website, as required under the Transparency in Coverage rule. Members can access the cost estimator tool on myCigna.com. Updated machine-readable files can be found on Cigna.com and/or CignaForEmployers.com on a monthly basis. Pursuant to Consolidated Appropriations Act (CAA), Section 106, CHLIC will submit certain air ambulance claim information to the Department of Health and Human Services (HHS) in accordance with guidance issued by HHS. Subject to change based on government guidance for CAA Section 204, CHLIC will submit certain prescription drug and health care spending information to HHS through Plan Lists Files (P1-P3) and Data Files (D1-D8) (D1-D2 for employers without integrated pharmacy Included in Medical Administration Fee Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 22 03/12/2025 product) aggregated at the Market Segment and State level, as outlined in guidance. Health Improvement Fund Health Improvement Fund For clinical/wellness/behavioral programs offered by CHLIC that are purchased, CHLIC will establish a Health Improvement Fund in the amount of $50,000.00. This fund will be used to defray the cost of CHLIC designated and arranged health and wellness improvement programs (e.g. biometric screenings, flu shots) for Employees of Employer and to reward participation in these programs. The Health Improvement Fund is a one-time credit to be used from January 1, 2025- December 31, 2025. Unused funds cannot be rolled over and CHLIC must pre-approve use of the Health Improvement Fund. The Health Improvement Fund shall be extinguished upon notice of termination of the Agreement and any fund amount not used prior to the notice of termination of the Agreement shall only be available to Employer for the purpose of funding the cost of those reimbursable services provided prior to such notice of termination. Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 23 03/12/2025 Exhibit B – Services BANKING AND ADMINISTRATION Excluding Health Savings Account Furnishing CHLIC’s standard Bank Account activity data reports to Employer as and when agreed upon. CHLIC’s administration of the Plan does not include performing obligations, if any, under state escheat or unclaimed property laws. It is Employer’s responsibility to determine the extent to which these laws may apply to the Plan and to comply with such laws. All Products If Employer has elected, pursuant to section 63 of the New York Health Care Reform Act of 1996 (section 2807-t of the Public Health Law) ("the Act"), to pay the surcharge on claims and assessment on covered lives directly to the New York Public Goods Pool as set forth in section 63 and has consented to the conditions set forth in section 63, CHLIC shall file such forms and pay such surcharge and assessment on covered lives on behalf of Employer through the Bank Account to the extent set forth in section 63. For Employers with Dental or Dental and Pharmacy coverage only, CHLIC shall file such forms and pay such surcharge but not assessments on covered lives on behalf of Employer through the Bank Account to the extent set forth in section 63. Such obligation shall end immediately upon Employer's failure to provide any information required by CHLIC to fulfill this obligation, the failure to comply with any requirement imposed upon Employer pursuant to the Act or the failure of Employer to sufficiently fund the Bank Account. In addition, where permitted and agreed to by CHLIC, CHLIC will file applicable forms and pay on behalf of Employer and/or the Plan any assessment, surcharge, tax or other similar charge which is required to be made by Employer and/or the Plan based on covered lives and/or paid claims or otherwise in accordance with and as required by other applicable state and/or federal laws and regulations and the Bank Account will be charged for any such payments made by CHLIC. CHLIC’s obligation to pay on behalf of Employer shall end immediately upon Employer’s failure to sufficiently fund the Bank Account. All Products CLAIM ADMINISTRATION Excluding Health Savings Account Calculate benefits, check and/or electronic payments disbursed from the Bank Account. Bank Account payments will appear in Employer’s standard Bank Account activity data reports. All Products CHLIC’s generic claim forms are made available to Employer and eligible individuals. All Products Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 24 03/12/2025 CHLIC’s Special Investigations Unit will investigate, pend, recommend denial of claims in whole or in part, and/or reprocess claims, as appropriate. All Products Discuss claims, when appropriate, with providers of health services. All Products Perform, based on CHLIC’s book of business internal audits of plan benefit payments on a random sample basis. All Products (excluding Pharmacy) Claim control procedures reported annually in Service Organization Controls (SOC) 1 Reports issued in accordance with American Institute of Certified Public Accountants Statement on Standards for Attestation Engagements (AICPA SSAE) No. 18 Report (or any applicable successor thereto). All Products (excluding Vision) Respond to Insurance Department complaints. All Products Designated toll-free telephone line for Member and Provider calls to CHLIC Service Centers. All Products Member Explanation of Benefit (“EOB”) statements including, when applicable, notice of denied claims, denial reason(s) and appeal rights. All Products (excluding Pharmacy) Verify enrollment and eligibility using Member information submitted by Employer and/or its authorized agent. All Products Medical Only CHLIC’s enrollment methods are made available to Employer for enrolling individuals into the Plan. All Medical Products CHLIC’s standard ID card with toll-free telephone number are prepared for Members. All Medical Products Administration of subrogation/conditional Claim Payment (terms described in Exhibit E). All Medical Products PLAN BOOKLET Prepare and make accessible Member benefit booklet drafts to Employer. All Products UNDERWRITING SERVICES 5500 Schedule C reporting. All Products 5500 Schedule A or Annual Reconciliation Disclosure reporting (when applicable) All Products CHLIC’s standard Underwriting services: a) benefit design analysis b) projected cost analysis. All Products HIPAA INDIVIDUAL RIGHTS Handling of requests from Members for access to, amendment and accounting of protected health information, and requests for restrictions and alternative communications as required under federal HIPAA law and regulations, as set out in this Agreement and its Exhibits. All Products Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 25 03/12/2025 COST CONTAINMENT Maximum reimbursable charge determinations of non-Participating Provider charges for covered services. All Medical Products CHLIC’s standard cost containment controls: Application of non-duplication and coordination of benefits rules and coordination with Medicare. All Medical Products Delivery of information, as necessary, regarding standard application of non -duplication or coordination of benefits. All Medical Products Review of medical bills in accordance with CHLIC’s then current Medical Bill Review program. All Medical Products Medical Cost Containment, as described in the Schedule of Financial Charges. All Medical Products Annual reporting of CHLIC’s standard cost containment results upon Employer’s request. All Medical Products REPORTING Summary reports of medical cost and utilization experience (where applicable), upon completion of internal report generation, are available through Cigna's web site, CignaforEmployers.com. All Medical Products Claim Reporting: CHLIC will provide standard banking and financial report information based upon paid claim data. CHLIC will not provide information on incurred-but-not reported claims, projected claims, pre-certifications of coverage, case management information or information on a Member’s prognosis or course of treatment. All Medical Products Upon request from the Employer, Individual Stop Loss Reporting is an optional service provided at an additional fee to employers who have individual stop loss through another entity other than CHLIC. CHLIC will provide its standard Individual stop loss reporting package, which includes banking and financial information based upon paid claims data, only after the stop loss carrier and Employer have executed CHLIC’s standard Non-Disclosure/Data Sharing Authorization Agreements. Aggregate Stop Loss Reporting is not provided as part of the standard reporting package as Employers can access claim and banking reports necessary to support aggregate stop loss administration via Cigna’s web site, CignaforEmployers.com. CHLIC will not provide documentation and information, including but not limited to, incurred-but-not-paid claims, projected claims, pre-certifications of coverage, case management records and notes, course of treatment or prognosis, and internal audits. CHLIC does not allow stop loss carriers to audit CHLIC’s claims administration under the medical benefit plan, however, the Employer’s audit rights are set forth in the Agreement. For the sake of clarity, as it is possible that certain All Medical Products Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 26 03/12/2025 information, documentation, data and/or reports that are required by the stop loss carrier prior to reimbursement under Employer’s stop loss policy will not be available for stop loss policy administration, Employer is responsible for verifying any such required information with its stop loss carrier. MEMBER EXTERNAL REVIEW PROGRAM CHLIC contracts with a minimum of three (3) independent review organizations that meet the Patient Protection and Affordable Care Act (PPACA) external review requirements. Members may appeal eligible claims requiring medical judgment to an external independent review organization which is selected by CHLIC on a random basis. If Employer has chosen not to participate in this program, the Employer may be responsible for making other arrangements to meet the Patient Protection and Affordable Care Act (PPACA) external review requirements. All Medical Products MEDICAL MANAGEMENT SERVICES CHLIC provides integrated medical management that includes (depending upon the terms of the Plan) the following core services. Pre-Admission Certification and Continued Stay Review (PAC/CSR) services to certify coverage of acute and sub-acute inpatient admissions/stays or provides guidance to appropriate alternative settings. Administered in accordance with CHLIC’s then applicable medical management and claims administration policies, practices and procedures. All Medical Products Case Management, a service designed to provide assistance to a Member who is at risk of developing medical complexities or for whom a health incident has precipitated a need for rehabilitation or additional health care support. All Medical Products Assist providers with resources and tools to enable them to develop long term treatment plans in the management of chronic or catastrophic cases. All Medical Products The Cigna HealthCare Healthy Babies Program is an educational program which provides Member with prenatal care education and resources to help them better manage their pregnancy. Other benefits of this program include the Health Information Line, high risk maternity and pregnancy information on myCigna.com. All Medical Products HealthCare Cost and Quality tools available on myCigna.com and myCigna mobile app. All Medical Products A panel of physicians and other clinicians to assess the safety and effectiveness of new and emerging medical technologies. The panel meets monthly to review and update coverage policies. All Medical Products Health Information Line is a service that provides twenty-four (24) hour toll free access to nurses who provide convenient and confidential services. Health Information Line nurses can help guide All Medical Products Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 27 03/12/2025 Members in finding the right care, make informed decisions about symptom-based health issues the Member is experiencing when they call the Health Information Line and recommend appropriate settings for care. Health Information Line nurses can help inform and educate Members about a wide variety of health and medical information, including access to a library of English and Spanish podcasts. Cigna LifeSOURCE Transplant Network® contracts with more than one hundred seventy (170) independent transplant facilities which includes over eight hundred (800) transplant programs and provides access to solid organ and bone marrow/stem cell transplantation while improving cost containment and reducing financial risk. All Medical Products A health education program that delivers mailings to Members with certain conditions. All Medical Products Behavioral health services are provided/arranged by a CHLIC affiliate (details available upon request), including utilization review and case management for both inpatient and outpatient, in - network behavioral health services. OAP Products: (All Members) Implement a quality oversight process that includes monitoring of utilization management performance measurements and a continuous quality improvement process when warranted. All Medical Products Transition of care services to allow Members with defined conditions to continue treatment with non-Participating Providers after enrollment for continued uninterrupted care for a limited time. All Medical Products Except Comprehensive and Indemnity Focused utilization management of outpatient procedures and identification of appropriate alternatives. Administered in accordance with CHLIC’s then applicable medical management and claims administration policies, practices and procedures. All Medical Products with Care Management Preferred NETWORK MANAGEMENT SERVICES CHLIC, and/or its affiliates or contracted vendors shall: Provide or arrange access to the applicable network of Participating Providers to furnish health care services/products to Members at negotiated rates and methods of reimbursement (e.g. fee-for service, fixed per person per period, per diem charges, incentive bonuses, case rates, withholds etc.). The amount and type of negotiated reimbursement may vary depending upon the type of plan. For example, a hospital may accept less for patients enrolled in certain types of plans than others. In addition, CHLIC may contract with Participating Providers and other parties (for example Independent Practice Associations) for performance-based incentive payments to promote quality of care, patient safety and cost efficiency. Where CHLIC has contracted with an affiliate All Medical Products Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 28 03/12/2025 for the provision of services by certain health care providers, amounts paid for claims under this arrangement may include amounts to reimburse CHLIC’s affiliate for its services, and the amounts paid for claims to the affiliate may be different than the amount paid to the rendering provider. CHLIC and/or its affiliates may retain or absorb any such difference; Credential and re-credential Participating Providers in accordance with CHLIC’s credentialing requirements and ensure that third-party network vendors credential/re-credential Participating Providers in accordance with CHLIC’s requirements; All Medical Products Monitor Participating Provider compliance with protocols and procedures for quality, Member satisfaction, and grievance resolution; All Medical Products Facilitate the identification of Participating Providers by Members; and All Medical Products Designated toll-free telephone line for Member and Provider calls to CHLIC Service Centers. All Medical Products Access to virtual on-demand urgent care, scheduled primary care, and scheduled behavioral health visits via phone or video, and virtual dermatology visits via secure messaging. Members may access this service via myCigna.com or the myCigna app. All Medical Products EVERNORTH CARE GROUP SERVICES The Cigna HealthCare of Arizona, Inc. staff model Evernorth Care Group (formerly known as Cigna Medical Group or “CMG”) is a multispecialty participating provider group located in metropolitan Phoenix, Arizona. Cigna Healthcare of Arizona, Inc. and Evernorth Care Group are affiliates of CHLIC. Evernorth Care Group’s integrated care delivery model and population health management team work together to facilitate the way in which patients and doctors communicate and interact in order to increase patient satisfaction and improve health outcomes. Plan Participants may at some time receive treatment from an Evernorth Care Group facility or provider even if they do not reside in Arizona (as when traveling). Plan Participants utilizing Cigna participating provider networks in Arizona may access certain specialty and/or ancillary services (such as urgent care services) through the Evernorth Care Group system. For covered services provided to Participants, Evernorth Care Group is paid at the rates in effect at the time of service (as may be revised from time to time). Representative rates for routinely performed services are available upon request. If the Plan requires or allows Participants to select a primary care provider (“PCP”), Phoenix area All Medical Products Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498 Administrative Services Only Agreement for Eagle County Government, a Body Corporate and Politic Cigna Health and Life Insurance Company 29 03/12/2025 Participants who do not select a PCP during open enrollment may be assigned to or otherwise encouraged to consider an Evernorth Care Group PCP. Evernorth Care Group has established collaborative referral relationships with specialty and ancillary providers in Cigna's participating provider networks, which includes affiliated entities. Evernorth Care Group may also receive applicable performance-based incentive payments for its participation in programs designed to improve quality, patient safety and affordability. The incentive payments that Evernorth Care Group may receive will be determined using the same performance measures and reward formula as used in determining the incentive payments made to similarly situated non-Cigna affiliated provider entities. Docusign Envelope ID: 2625E820-2DBD-4ECF-8B81-E77374C85498