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"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 pian 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")or a pharmaceutical manufacturer to Claim Administrator and consents <br /> to Claim Administrator's retention of all such rebates. The Rebate Credit will be provided from Claim Administrator's own <br /> assets and may or may not equal the entire amount of rebates actually provided to Claim Administrator or expected to be <br /> provided. Rebate Credits shall not continue after termination of the Prescription Drug Program. Employer agrees that any <br /> Rebate Credit provision in the governing Administrative Services Agreement to the contrary is hereby superseded. <br /> Claim Administrator Provider <br /> Group Number(s): P22346, PE4337, PJ1005, PJ1009 <br /> ®%of ADP Savings: 1.19% <br /> ❑$per Covered Employee per month:$ <br /> ❑ Group with multiple Provider Access Fees by services(e.g., CMM, and/or PPO plans): <br /> Group Number(s): <br /> ❑%of ADP Savings: % <br /> ❑$per Covered Employee per month: $ <br /> BlueCard Program/Network access fees: Available upon request. <br /> Administrative Line ItemFrequency <br /> SEE ADDITIONAL PROVISIONS <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 /> 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 /> tL 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 8 <br />