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FEE SCHEDULE <br /> Employer shall pay amounts Claim Administrator bills Employer for benefit claims Claim Administrator processes on <br /> Employer's behalf as well as administrative fees as set forth in this Fee Schedule. <br /> Payment Specifications Ej NO CHANGES [:1 SEE ADDITIONALPROVISIONS <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(cannot be selected if Check is selected as payment method above) <br /> ®Monthly <br /> Claim Settlement Period: ❑Weekly ®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,pleasespecify: months. <br /> Administrative Per Employee Per Month NO CHANGES E]SEE ADDITIONAL PROVISIONS <br /> Charges <br /> PPO <br /> Administrative Fee $60.10 $ $ $ <br /> Dental $ $ $ $ <br /> Claims Fiduciary $ $ $ $ <br /> Advanced Payment Review <br /> 25% % % % <br /> *Medical Drug Rebate Credit $(2.50) $( ) $( ) $( ) <br /> 'Rebate Credit for the Prescription Drug Program $(128.45) $( ) $( ) $( ) <br /> Telehealth (Virtual Visits) $0.52 $ $ $ <br /> Wellbeing Management $ $ $ $ <br /> Health Advocacy Solutions $ $ $ $ <br /> Pharmaceutical Care Management(Retrospective) <br /> (No cost if both HAS and Prescription Drug $ $ $ $ <br /> Program are elected) <br /> Commissions: $ $ $ $ <br /> Commissions: $ $ $ $ <br /> Commissions: $ $ $ $ <br /> Other: Member Rewards <br /> List Service: $1.50 $ $ $ <br /> Other: Select Service Category <br /> List Service: $ $ $ $ <br /> Other: Select Service Category <br /> List Service: $ $ $ $ <br /> Other: Select Service Category <br /> List Service: $ $ $ $ <br /> Miscellaneous: $ $ $ $ <br /> Miscellaneous: $ $ $ $ <br /> Total $ $ $ $ <br /> Proprietary and Confidential Information of Claim Administrator <br /> Not for use or disciosure outside Claim Administrator,Employer,their respective affiliated companies and third-parry representatives,except <br /> with written permission of Claim Administrator. <br /> I GEN ASO VBD BPA(Rev.06.24)Blue Cross and Blue Shield of Illinois,a Division of Health Care Service Corporation,a Mutual <br /> Legal Reserve Company,an Independent Licensee of the Blue Cross and Blue Shield Association 7 <br />