Laserfiche WebLink
Management of the Virtual Visits Program $ $ $ $ <br /> *Rebate Credit for the Prescription Drug Program $ 3j 7.02 $ $ $ <br /> PEPM1 <br /> Commissions $Net of $ $ $ <br /> commissions <br /> Other: Select Service Category $2.00 $ $ $ <br /> List Service: Member Rewards <br /> Other: Other Services $,45 PEPM $ $ $ <br /> List Service: MD Live <br /> Other: Select Service Category $ $ $ $ <br /> List Service: <br /> Other: Select Service Category $ $ $ $ <br /> List Service: <br /> Miscellaneous: $ $ $ $ <br /> Miscellaneous: $ $ $ $ <br /> Total $ $ $ $ <br /> *The Rebate Credit is a per Covered Employee per month credit applied to the monthly billing statement. The Employer <br /> and Claim Administrator have agreed to the Rebate Credit and Employer agrees that it and its group health plan have no <br /> right to, or legal interest in, any portion of the rebates, either under the pharmacy benefit or the medical benefit, actually <br /> provided by the Pharmacy Benefit Manager(PBM) to Claim Administrator and consents to Claim Administrator's retention <br /> of all such rebates. The Rebate Credit will be provided from Claim Administrator's own assets and may or may not equal <br /> the entire amount of rebates actually provided to Claim Administrator by the PBM or expected to be provided. Rebate <br /> Credits shall not continue after termination of the Prescription Drug Program. Employer agrees that any provision in the <br /> governing Administrative Services Agreement to the contrary is hereby superseded. <br /> Administrative Line Item Charges Frequency <br /> Other: Select Service Category Select Billing Frequency $ <br /> List Service: If applicable, describe other: <br /> Other: Select Service Category Select Billing Frequency $ <br /> List Service: If applicable, describe other: <br /> Other: Select Service Category Select Billing Frequency $ <br /> List Service: If applicable, describe other: <br /> Other: Select Service Category Select Billing Frequency $ <br /> List Service: If applicable, describe other: <br /> Miscellaneous: Select Billing Frequency $ <br /> If applicable, describe other: <br /> Miscellaneous: Select Billing Frequency $ <br /> If applicable, describe other: <br /> Total: <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, 5 <br /> an Independent Licensee of the Blue Cross and Blue Shield Association <br />