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❑ Wellness Incentives ® Covered under a pharmacy benefit(if selected, the <br /> ® Well onTargee PBM Fee Schedule Addendum must be attached and is <br /> part of this BPA.) <br /> ❑ Blue Directions(Private Exchange) (If selected, the <br /> Blue Directions Addendum is attached and made a part ® Covered under the medical benefit or Blue Script <br /> of the Agreement.) Pharmacy Network(Select one): <br /> ❑ Other Select Product ®Traditional Select Network <br /> ❑ Other Select Product <br /> ❑Advantage Network <br /> ❑ Other Select Product <br /> ❑ Preferred Network(Not offered with Blue Script) <br /> ❑ Other Select Product <br /> ❑ Elite Network(Not offered with Blue Script) <br /> ❑ Other <br /> ❑ Network on PBM Fee Schedule Addendum <br /> ❑ Other PPO Drug List: Basic Drug List <br /> Other(please specify): <br /> Ancillary Services: <br /> ❑ Dental Plan Services <br /> ❑ Vision Plan Services <br /> ® Stop Loss (if selected, complete separate Exhibit to <br /> the Stop Loss Coverage Policy) <br /> ❑ Dearborn National Life Insurance (if selected, <br /> complete separate Life application) <br /> ® COBRA Administrative Services (if selected, <br /> complete separate COBRA Administrative Services <br /> Addendum to the BPA) <br /> FEE SCHEDULE <br /> Payment Specifications NO CHANGES SEE ADDITIONAL <br /> PROVISIONS <br /> Employer Payment Method: ❑ Online Bill Pay ® Electronic ❑Auto Debit ❑ Check <br /> Employer Payment Period: ❑Weekly(cannot be selected if Check is selected as payment method above) <br /> ❑ Semi Monthly ® Monthly <br /> Claim Settlement Period: ® Monthly <br /> Run-Off Period: Employer Payments are to be made for 12 months following end of Fee Schedule Period. <br /> Standard is twelve (12) months. <br /> Fee Schedule Period: To begin on Effective Date of Coverage and continue for 12 months. If other than 12 <br /> months, please specify: Months <br /> EmployeeAdministrative Per • CHANGES SEE ADDITIONAL <br /> •EPM) Charges PROVISIONS <br /> PPO <br /> Administrative Fee $59.02 $ $ $ <br /> Dental $ $ $ $ <br /> Claims Fiduciary $ $ $ $ <br /> Proprietary and Confidential Information of Claim Administrator <br /> Not for use or disclosure outside Claim Administrator,Employer,their respective affiliated companies and third party representatives,except <br /> with written permission of Claim Administrator. <br /> HCSC IL GEN ASO BPA(Rev.08/17) A Division of Health Can:Service Corporation,a Mutual Legal Reserve Company, 4 <br /> an Independent Licensee of the Blue Cross and Blue Shield Association <br />