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— ❑ American Heaithways: Select from Pull Down Program fees are "per participating Covered Person per <br /> �� month" <br /> I <br /> I — <br /> '�, Conditions: Package A - Package B - Package C - <br /> I�-- - <br /> Fees Fees Fees <br /> Diabetes: $ $ $ <br /> � Chronic Heart Disease: $ $ $ <br /> I Chronic Obstructive Pulmonary Disease: $ $ Not Applicable <br /> I, Asthma: $ $ Not Applicable <br /> I, Impact Conditions: $ Not Applicable Not Applicable <br /> � <br /> PAYMENT SPECIFICATIONS <br /> � . . <br /> � Payment Method: � Transfer Payment ❑ Post Payment <br /> I Payment Period: ❑ Daily � Weekly ❑ Bi-Weekly ❑ Monthly ❑ Other(please specify): <br /> i <br /> '�,r Claim Settlements: � Monthly ❑ Quarterly ❑ Other(please specify): <br /> ,, If Transfer Payment: <br /> ', Method of Transfer Payment: � Wire Transfer ❑ Draft ❑ Electronic Fund Transfer <br /> ' ❑ Other please specify): <br /> ' Fee Schedule Period: � 12 Months ❑ Other(please specify): Months <br /> —. <br /> �, Run-Off Period <br /> , Number of months Transfer or Post Payments are to be made following end of Fee Schedule Period: <br /> � � 3 months ❑ 6 months ❑ 9 months ❑ 12 months (sta) ❑ Other: months after termination. <br /> r— <br /> � Final Settlement: Final Settlement is to be made within sixty (60) days (sta)after end of Run-Off Period. <br /> � <br /> OTHER PROVISIONS: <br /> 1. Certificate of Creditable Coverage: � Yes ❑ No <br /> If yes: The Employer directs the Claim Administrator to issue fo individuals, whose coverage under the Plan terminates <br /> during the term of the Administrative Services Agreement, a Certificate of Creditable Coverage. The Certificate of <br /> Creditable Coverage shall be based upon information required for issuance of the Certificate of Creditable Coverage <br /> provided to the Claim Administrator by the Employer and coverage under the P/an during the term of the <br /> Administrative Services Agreement. <br /> 2. Case Management Program/Medical Services Advisory: � Yes ❑ No <br /> If yes: The undersigned represenfative authorizes provision of alternative benefits for services rendered to Covered Persons in <br /> accordance with fhe provisions of the Administrative Services Agreement and fhe Employer's plan document. <br /> 3 Stop Loss Coverage purchased: � Yes ❑ No (If yes, complete a separate Exhibit to the Stop Loss Coverage Policy) <br /> 4 Fort Dearborn Life Insurance purchased: ❑ Yes � No (If yes, complete separate Life application) <br /> 5 Health Care Account (HCA) Administrative Services Purchased: ❑ Yes � No (If yes, complete separate HCA <br /> application) <br /> 6. COBRA Administrative Services Purchased: ❑ Yes � No (If yes, comp/ete separate COBRA application) <br /> 7. Electronic Issuance: In the event, the Employer requests any document from the Claim Administrator describing the <br /> benefits under or the administration of the Plan, the Employer consents to receive such documents, via an electronic <br /> GA-10-4 HCSC IL Rev. 09/12/07 (On-line Version) page 4 <br />