Cc. Notwithstanding any other provision of this Article 13, Anthem will periodically perform audits of Provider
and Vendor contracts and other Claims audits to determine if Claims were accurately paid. Anthem shall
have authority to enter into a settlement or compromise regarding these audits, including, but not limited to,
the right to reduce future reimbursement to Provider or Vendor in lieu of a lump sum settlement. If Anthem
conducts an audit and makes a recovery as a result of such audit of Claims accuracy, then Anthem shall
provide Employer a credit, after a reduction of third party vendor fees or costs, if any. Anthem shall credit
Employer a proportionate share of the net recovery equal to the ratio of (1) total Members' Paid Claims to
such Provider or Vendor for the audit period, to (2) total payments made to such Provider or Vendor for all
of Anthem's business during the audit period. Notwithstanding the above, Anthem shall retain any
recoveries made from a Provider or Vendor resulting from any audits if the cost to administer the refund is
likely to exceed the total recovery from the Provider or Vendor.
d. Anthem shall credit Employer net recovery amounts after deduction of fees and costs as set forth in this
Article 13 not later than 150 days following the receipt of such recovery amounts. If Anthem does not credit
Employer within 150 days of its receipt of recovery amounts, Anthem shall pay Employer interest calculated
at the Federal Reserve Funds Rate in effect at the time of the payment. Anthem may have contracts with
Network Providers or Vendors or there may be judgments, orders, settlements, applicable laws or
regulations that limit Anthem’s right to make recoveries under certain circumstances. Employer agrees that
Anthem shall not be responsible for any such amounts that it is unable to recover from such Providers or
Vendors. Notwithstanding the provisions of this Article 13, Anthem may, but is not required to, readjudicate
Claims or adjust Members’ cost share payments related to the recoveries made from a Provider or a
Vendor. In no event, however, will Anthem be liable to credit Employer for any recovery after the
termination date of this Agreement and any Claims Runout Period, and the Employer acknowledges and
agrees that such sums shall be retained by Anthem as reasonable compensation for recovery services
provided by Anthem.
ARTICLE 14 - PHARMACY BENEFITS AND SERVICES
a. If applicable to Plan benefits and as indicated in Schedule B of this Agreement, Anthem, through PBM, shall
provide the following Prescription Drug management services:
1. Anthem shall offer Employer access to a network of pharmacies that have entered into contractual
arrangements with PBM under which such pharmacies agree to provide pharmacy services to
Members and accept negotiated fees for such services ("Network Pharmacies"). Anthem shall
determine, in its sole discretion, which pharmacies shall be Network Pharmacies, and the
composition of Network Pharmacies may change from time to time.
2. Anthem will furnish and maintain a drug formulary for use with the Plan, and Anthem shall
periodically review and update its formulary. The Employer shall adopt such formulary as part of
the design of the Plan. Unless mutually agreed to in writing by the Parties, upon termination of the
Agreement, the Employer shall cease adoption and use of Anthem's formulary as part of its Plan.
The drug formulary will be made available to Members on Anthem's web site and upon request
may be provided to Employer in a mutually acceptable format for Employer's distribution to
Members.
3. Anthem shall offer Employer a mail order pharmacy program, through which Members may
receive mail order prescription services. Additional fees for express mail, shipping or handling
may be charged to Members. Anthem shall also offer Employer a specialty pharmacy program,
through which Members may receive specialty pharmacy prescription services. Anthem shall
provide all necessary information and forms to Members to obtain these services.
4. Anthem shall arrange for the processing of Prescription Drug Claims in accordance with the
Benefits Booklet.
Enterprise Administrative Services Agreement — October 2012 Master Template 12
City of Nashua 06/17/2013
