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is <br />GROUP BENEFITS SERVICES AGREEMENT <br />NON- PARTICIPATING <br />.L This <br />Agreement is between the Employer named in the Schedule and the Texas Municipal League Group <br />Benefits Risk Pool, 1821 Rutherford Lane, Suite 300, Austin, Texas 78754 <br />SCI >< MULE <br />l.,' . 1. <br />Employer: City of Paris <br />2: <br />ry� n Place of Delivery: Austin, Texas <br />, <br />. 3. <br />Effective Date: May 1, 1997 <br />f1 <br />s;. 4, <br />Monthly Service Charge per employee per month: <br />' <br />Claims Administration <br />Medical $ 6.75 <br />i <br />Dental <br />$ 0.80 • <br />'t <br />Vision $ 0.00 <br />�,,;��` ; . <br />• Utilization Review $1.60 <br />,,,,, , <br />' ;; , " <br />• PPO Access Fee $1.25 <br />to I-A, <br />5. <br />Optional Services (per employee per month) <br />'�'.. <br />• Transplant Centers $ 0.15 <br />First Call $ 0.00 <br />• High Risk Pregnancy $ 0.00 <br />Medical Conversion $ 0.00 <br />HIPAA Compliance Adm. $ 0.00 <br />• $ 0.00 <br />;�.. ;;, <br />• $0.00 <br />6. <br />Total $10.55 <br />Health Check - AutoAudit No Charge <br />Large Case Management $65.00 /hr as required <br />Custom Reports (1 /yr included) $60.00 /programming hour <br />Rx Card Claims $ 0.56 /claim <br />PPO Directories Actual Cost <br />a <br />EXHIBIT A <br />