HomeMy WebLinkAboutHR14-321 - Amendment - Premera Blue Cross - Administrative Service Contract - Retiree Drug Subsidy - 09/01/2014 M .
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CONTRACT COVER SHEET
This is to be completed by the Contract Manager prior to submission
to City Clerks Office.'AII portions are to be completed.
If you have questions, please contact City Clerk's Office.
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Vendor Name: j iE .ryttf t _(
Vendor Number: 1
JD Edwards Number
Contract Number:
This is assigned by City Clerk's Office
Project Name: J--
Description: ❑ Interlocal Agreement El Change OrderAmendment ❑ Contract
❑ Other:
Contract Effective Date, i Termination Date: r), j
Contract Renewal Notice (Days): Kf, 1' ;
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Contract Manager.. Department: '_,
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S:PublIc\RecordsManagement\Forms\ContractCover\adcc7832 1 11/08
PREMERA I ED
AMENDMENT TO THE
RETIREE DRUG SUBSIDY
ADMINISTRATIVE SERVICES AGREEMENT
between
PREMERA BLUE CROSS
and
CITY OF KENT
This Amendment explains some changes to the Retiree Drug Subsidy Administrative Services Agreement(the
"Agreement") between Premera Blue Cross("Company"or"we,"'us,"or"our") and City of Kent ("Sponsor").
The purpose of this Amendment is to revise Appendix A. This Amendment takes effect on September 1, 2014
(the"Effective Date"). The changes are as follows:
Appendix A is revised to read:
APPENDIX A
Effective Date: September 1, 2014
Plan Year: January 1, 2015 through December 31, 2015
Fees: Pursuant to Article IV of this Agreement, Sponsor agrees to pay
Company 15%of reconciled subsidy amount for the
services provided under Article III of this Agreement.
Due Date for Fee Payment: 10 days after receipt of invoice
Frequency of Claims Submission: Annual
All other provisions of the Agreement remain unchanged. This Amendment forms a part of the Retiree Drug
Subsidy Administrative Services Agreement between the Sponsor and Premera Blue Cross. It should be kept
with the Agreement for future reference.
IN WITNESS WHEREOF the parties hereto sign their names as duly authorized officers and have executed this
Amendment.
City of Kent
BY: �� DATE: J(® 1114,
TITLE:
ADDRESS:
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Premera Blue Cross
BY: A" ""- 11r � DATE: September 10, 2014
H.R. Brereton Barlow
Chief Executive Officer
P.O. Box 327
Seattle, WA 98111-0327
DSUBA(08-2010)
An Independent Licensee at the Blue Cross Blue Shield Association