PBM has negotiated programs with pharmaceutical manufacturers under which rebates for certain
Prescription Drugs dispensed to Members are made directly to PBM ("Drug Rebate Programs"). Such
Drug Rebate Programs are not based on the drug utilization of any one Employer Plan, but rather are
based on the drug utilization of all individuals enrolled in PBM managed programs. In many cases the
rebates are conditioned on certain Prescription Drugs being included on the formulary that Anthem requires
Employer to adopt as part of the Plan. PBM will pay Anthem a portion of the rebates it receives (such
portion being referred to in this Agreement as "Drug Rebates"). Anthem shall pay Employer an amount
attributable to its actual or estimated receipt of the Drug Rebates as described in Section 3(A) of Schedule
A.
Anthem may receive and retain administrative fees from PBM or directly from pharmaceutical
manufacturers. In addition, Anthem may receive and retain service fees from pharmaceutical
manufacturers for providing services (e.g., Provider and Member education programs that promote clinically
appropriate and safe dispensing and use of Prescription Drugs). For purposes of this Agreement,
administrative fees and service fees received by Anthem or PBM shall not be considered Drug Rebates.
lf Employer terminates the pharmacy benefits portion of its Plan with Anthem at any time, then Anthem shall
have the right to amend the Administrative Services Fee indicated in Section 3(A) of Schedule A.
ARTICLE 15 - INTER-PLAN ARRANGEMENTS (THE LANGUAGE IN THIS ARTICLE IS REQUIRED BY BCBSA.)
a.
Out of Area Services. Anthem has a variety of relationships with other Blue Cross and/or Blue Shield
Licensees referred to generally as "Inter-Plan Programs." Claims for certain services may be processed
through one of these Inter-Pian Programs and presented to Anthem for payment in accordance with the
rules of the Inter-Plan Programs policies then in effect. The Inter-Plan Programs available to Members
under this Agreement are described generally below. Typically, Members’ Claims are processed through an
Inter-Plan Program when Members obtain care from health care Providers that have a contractual
agreement (i.e., are "Network Providers") with a local Blue Cross and/or Blue Shield Licensee ("Host Blue").
In some instances, Members may obtain care from non-Network Providers. Anthem's payment practices in
both instances are described below.
In the case of an HMO or EPO plan, Anthem covers only limited health care services received outside of
the service area. For the explanations below, references to Covered Services refer to emergency care and
urgent care obtained outside of the geographic area Anthem and/or the designated Anthem Affiliate serve.
Any other service of the HMO or EPO plan will not be covered when processed through any Inter-Plan
Program arrangement.
BlueCard® Program. Under the BlueCard® Program, when Members access Covered Services within the
geographic area served by a Host Blue, Anthem will remain responsible to Employer for fulfilling Anthem's
contractual obligations. However, in accordance with applicable Inter-Plan Programs policies then in effect,
the Host Blue will be responsible for providing such services as contracting and handling substantially all
interactions with its Network Providers. The financial terms of the BlueCard Program are described
generally below. Individual circumstances may arise that are not directly covered by this description;
however, in those instances, Anthem's action will be consistent with the spirit of this description.
1. Liability Calculation Method Per Claim. The calculation of the Member liability on Claims for
Covered Services processed through the BlueCard Program will be based on the lower of the
Network Provider's Billed Charges or the negotiated price made available to Anthem by the Host
Blue.
The calculation of Employer liability on Claims for Covered Services processed through the
BlueCard Program will be based on the negotiated price made available to Anthem by the Host
Blue. Sometimes, this negotiated price may be greater than Billed Charges if the Host Blue has
negotiated with its Network Provider(s) an inclusive allowance (e.g., per case or per day amount)
for specific health care services. Host Blues may use various methods to determine a negotiated
price, depending on the terms of each Host Blue's health care Provider contracts. The negotiated
price made available to Anthem by the Host Blue may represent a payment negotiated by a Host
Blue with a health care Provider that is one of the following:
i. an actual price. An actual price is a negotiated payment without any other increases or
decreases, or
Enterprise Administrative Services Agreement — October 2012 Master Template 13
City of Nashua 06/17/2013
