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� LINES OF BUSINESS <br /> . <br /> . . . . . - . . . <br /> I � Participating Provider Option �. Outpatient Prescription Drugs: <br /> ❑ Point of Service (BlueChoice) � Outpatient Prescription Drug Program <br /> ❑ Blue Choice Select � Covered under the medical benefit <br /> � �� Comprehensive Major Medical ❑ Dental <br /> ❑ Base Plus � Blue Care Connection <br /> SERVICE CHARGES <br />' � . <br /> I <br /> % of Claim Payments or$ 51.38 per Covered Employee per month <br /> ! � Applies to all coverages <br /> I ❑ Different percentage(s) or amount(s) for the following types of coverages. <br /> i Please specify: <br /> �! Subscriber Share Methodology for Illinois Network Provider Claims Applies: � Yes ❑ No <br /> (if no,a letter declinin Subscriber Share Methodolo for Claims Processin must be attached to this Benefit Pro ram A lication. <br /> ' • • ' • . - � <br /> Group Number(s): P22346, P22347, P22348, P22349, 022346 <br /> � � % of ADP Savings: 2% <br /> � <br /> � ❑ $ per Covered Employee per month: $ <br /> I Complete for Groups with mulfiple Provider Access Fees by products(ie., CMM,PPO and/or POS plans): <br /> i Group Number(s : <br /> � r� % of ADP Savings: % <br /> �� $ per Covered Employee per month: $ <br /> • ' • . . . <br /> ; Prescription Drug Rebate: $ 5.76 per Covered Employee per month is the guaranteed Prescription Drug Rebate <br /> savin s reflected as a Prescri tion Dru Rebate credit. <br /> Reimbursement Provision: � Yes ❑ No <br /> iIf yes: It is understood and agreed that in the event the Claim Administrator makes a recovery on a third-party liability <br /> claim, the Claim Administrator will retain 25% of the net recover after attorne s' fees, if an , have been aid. <br /> Conversion Privilege: ❑ Yes � No If yes, conversion fee: $6,000 per conversion. <br /> ', Blue Care°Connection ("BCC") Program: Fee: $included in admin. per Covered Employee <br /> i Blue Care Advisor(includes Blue Care) per month for administration of the program. <br /> � Blue Care Custom <br /> G <br /> ' ❑ Health Dialog: Select from Pull Down Fee: $ per Covered Employee per month <br /> GA-10-4 HCSC IL Rev. 09/12/07 (On-line Version) page 3 <br />