Okaloosa County BOCC — June 17, 2014 — BlueMedicare — reading text

approved by us, such authorization or approval shall be considered given when provided in writing by a duly authorized officer of Florida Blue or his or her designee. D. Evidence of Coverage We will provide an Evidence of Coverage and ID Card for each Covered Retiree. The Evidence of Coverage will describe the coverage and benefits to be provided to Covered Persons by us. You agree that, if requested by us, you will distribute the Evidence of Coverage (and any Endorsements to it) and other coverage materials to Covered Persons. any person can change, alter, delete, add or otherwise modify the express written terms of this Agreement, which includes the terms of coverage and/or benefits set forth in the Evidence of Coverage, the Schedule of Benefits, and any other attachments, amendments or riders. J. Financial Responsibilities of the Group We reserve the right to recover any benefit payments made to or on behalf of any individual whose coverage has been terminated. Our recovery efforts may relate to benefit payments made for health care services rendered subsequent to the Covered Person's termination date and prior to the date notice of coverage termination is required to be made by you. Your cooperation with and support such recovery efforts is required. In the event that you do not comply with the notice requirements set forth in Subsection 5.A (Monthly Invoice), you shall be solely liable to us for Premium due until the effective date established by CMS for a Covered Person’s disenrollment. K. Indemnification You shall hold harmless and indemnify Florida Blue, against all claims, demands, liabilities, or expenses (including reasonable attorney fees and court costs), which are related to, arise out of, or are in connection with any of your acts or omissions, or acts or omissions of any of your employees, retirees or agents, in the performance of your obligations under this Agreement. We are not your agent, nor are you our agent, for any purpose. This paragraph shall only apply to the extent allowed under Florida Statutes § 768.28. L. Representations on the Group Application and the Enrollment Forms We rely on the information you and your Eligible Retirees provide to determine whether to issue coverage; the appropriate Premium and financing method; and eligibility for coverage. All such information must be accurate, truthful, and complete. Statements made on the Enrollment Forms are representations and not warranties. We may cancel, terminate, or void this Agreement if the information which you provide is fraudulent, or if you make an intentional misrepresentation. M. Reservation of Right to Contract We reserve the right to contract with any individuals, corporations, associations, partnerships, or other entities for assistance with the servicing of coverage and benefits to be provided by us or obligations due, under this Agreement. N. Service Mark You, on behalf of the Group and its Covered Retirees, hereby expressly acknowledge your understanding that this Agreement constitutes a contract solely between you and Florida Blue. We are an independent corporation operating under a license with the Blue Cross and Blue 11 S. COBRA You are solely responsible for determining when individuals are eligible for coverage under a Medicare Plan pursuant to the Consolidated Omnibus Budget Reconciliation Act (“COBRA”). You will notify us promptly of any COBRA elections. For more information on your COBRA responsibilities refer to the Benefit Administrator Guide. In consideration of the payment of Premiums when due and subject to all of the terms of this Agreement, Blue Cross Blue Shield of Florida, Inc. hereby agrees to provide each enrollee of the Okaloosa Board of County Commissioners the benefits of this Agreement as set forth in the attached Evidence of Coverage beginning on each enrollee’s effective date. The Group has selected the following plans and premiums: BlueMedicare Group PPO2Rx2 with supplemental Fitness at $346.60 per member, per month, and BlueMedicare Group Prescription Drug Plan (PDP) Rx2-Only at $165.29 per member, per month. The Group’s Agreement is effective as of October 1, 2014. IN WITNESS WHEREOF, the parties have executed this Agreement as of Blue Cross Blue Shield of Florida, Inc. Okaloosa Board of County Commissioners By: CK By: (Signature) i Cc) ° (Signature) Name: Lynn Esposito Name: (Please Print or Type) (Please Print or Type) Title: Vice President, Sales Operations Title: 13