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® Annual Premium(Due on the first day of the Current Policy Period): $19,395 <br /> E. The rates shown in this Application reflect a volume-based discount in an amount up to 3%of the Aggregate Stop-Loss <br /> Premium for the Policy Period. If ancillary coverage (B€ueCare Dental, Basic Life, Short-Term Disability, Long-Term <br /> Disability,Accident,Critical Illness and/or Vision product(s)), the election of which triggered the volume-based discount, <br /> lapses during the Policy Period, the Company reserves the right to remove the discount on the Aggregate Stop-Loss <br /> Premium. In such event, the Aggregate Stop Loss Premium will revert to the non-discounted amount, following sixty <br /> (60)days'prior notice to the Employer Group/Policyholder. <br /> F. Additional Provisions(if elected): <br /> 1. Retirees Covered (select if included): <br /> Pre-65: E or Post-65: rk� <br /> 2. Home Hospital Employer Groups Only: Nome Hospital Provider Number(s)subject to exclusion percentage per <br /> Item B.3. &C.3.: <br /> 3. Monthly Aggregate Accommodation: ❑ Yes ® No <br /> 4. Additional information: <br /> Effective.January 1,2025,for new business and renewals issued under this policy, BCBSIL reserves the right to apply <br /> lasers and adjust rates for the gene therapy ingredient costs and any claims risk. <br /> Subsequent renewals, if and when issued, will be subject to no new lasers or rate adjustments to the extent that the <br /> gene therapy ingredient cost for one or more of the gene therapies listed below is covered under the Plan administered <br /> by BCBSIL and was included in Paid Claims under the Plan. BCBSIL reserves the right to continue to laser and adjust <br /> rates for those members that were lasered in the prior policy period. <br /> 1. Hemgenix <br /> 2. Zynteglo <br /> 3. Luxturna <br /> 4. Skysona <br /> 5. Zolgensma <br /> 6. Elevidys <br /> 7. Roctavian <br /> 8. Casgevy <br /> 9. Lyfgenia <br /> 10. Lenmeldy <br /> 11. Beqvez <br /> This provision does not obligate BCBSIL to issue a renewal of the policy.This statement remains subject to all terms <br /> and conditions of the Policy,the most current Application,and any attachments included but not limited to the proposal <br /> and renewal documents. <br /> To the extent consistent with the terms of the Plan, "Gene therapy ingredient" is defined as the genetic, cellular, viral <br /> or other organic or inorganic materials administered to affect the condition for which they are prescribed. <br /> Fraud Notice: Any person who knowingly, with intent to injure, defraud or deceive any insurance company submits an <br /> application containing any false, incomplete, or misleading information, may be subject to prosecution and may be found <br /> guilty of a felony under state law and subject to punishment, including fines and/or imprisonment. Submission of false <br /> information in connection with this application may also constitute a crime under federal laws.All appropriate legal remedies <br /> will be pursued in the event of insurance fraud, including prosecution under Federal Mail or Wire Fraud statutes,andl or the <br /> 4 <br /> IL SL-APP Rev. 3.21 <br /> A Division of Health Care Service Corporation,a Mutual Legal Reserve Company <br /> an Independent Licensee of the Blue Cross and Blue Shield Association <br />