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City of South Bend <br />Group ID <br />00103525 <br />Summary <br />of Costs for the Renewal Contract Year from 01/01/2019 through 12/31/2019 <br />Current Subscribers <br />Per Subscriber Per Month Cost <br />FIXED COSTS: <br />Med/RX <br />Dent Vis <br />Med/Rx <br />Dent <br />_ <br />Vis <br />d.......� <br />Grand Total <br />Admin Fee / Network / UM <br />1,067 <br />0 <br />0 <br />$59.40 <br />$0.00 <br />$0.00 <br />$59.40 <br />Admin EnhClinPkg <br />1,067 <br />0 <br />0 <br />$5.05 <br />$0.00 <br />$0.00 <br />$5.05 <br />Admin ActWise HRA <br />108 <br />0 <br />0 <br />$2.75 <br />$0.00 <br />$0.00 <br />$2.75 <br />Broker's Commission <br />0 <br />0 <br />0 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />Specific SL Premium <br />1,067 <br />0 <br />0 <br />$48.04 <br />$0.00 <br />$0.00 <br />$48.04 <br />Aggregate SL Premium <br />0 <br />0 <br />0 <br />$0.00 <br />$0.00 <br />$0.00 <br />$0.00 <br />Total Fixed Costs (Illustrative) <br />1,067 <br />0 <br />0 <br />$112.77 <br />$0.00 <br />$0.00 <br />$112.77 <br />CLAIMS EXPENSE: <br />Expected Claims Liability <br />1,067 <br />0 <br />0 <br />$1,018.57 <br />$0.00 <br />$0.00 <br />$1,018.57 <br />Maximum Claims Liability <br />1,067 <br />0 <br />0 <br />N/A <br />N/A <br />N/A <br />N/A <br />TOTALCOST: <br />Estimated Annual Cost <br />Expected <br />Med/Rx <br />,........ <br />Dent <br />Vls <br />.,... <br />Grand Total <br />Fixed Cost <br />$1,443,886 <br />$0 <br />$0 <br />$1,443,886 <br />Expected Claims Expense <br />$13,041,770 <br />$0 <br />$0 <br />$13,041,770 <br />Total Expected Cost <br />$14,485,656 <br />$0 <br />$0 <br />$14 485,656 <br />Maximum <br />Fixed Cost <br />$1,443,886 <br />$0 <br />$0 <br />$1,443,886 <br />Maximum Claims Expense <br />N/A <br />N/A <br />N/A <br />N/A <br />Total Expected Maximum Cost <br />N/A <br />N/A <br />N/A <br />N/A <br />Renewal Contract is ASO / SSL / No ASL on a Paid basis <br />Renewal Specific Stop Loss Limit is $300,000 on a Per Member basis with Immediate Reimbursement and coverage applies to Medical; HOTr, MH/SUD; Rx; <br />Aggregate Stop Loss does not apply <br />Stop Loss Premium does not include broker commission <br />Specific Stop Loss Maximum: Unlimited; <br />This renewal includes EPHC fees, Non -Network and Traditional Savings fees, Rx Ancillary fees, and Program Integrity fees. <br />Anthem Health and Wellness Programs: Surgical Quality and Safety Management Program $300.00 per occurrence; <br />Signature and Title Date <br />Plan Annual Costs illustrated above are based on current enrollment <br />16143 10/23/2018 9:26 AM <br />