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LINES OF BUSINESS <br /> (Check all applicable products) <br /> � NO CHANGES ❑ See Additiona/Comments <br /> Managed Care Coverage: <br /> � Participating Provider Option (PPO) <br /> ❑ Point of Service (POS) (BlueChoice) <br /> ❑ BlueChoice Select <br /> ❑ Comprehensive Major Medical <br /> ❑ Base Plus <br /> Consumer Driven Health Plan: <br /> ❑ Health Care Account(HCA)Administrative Services <br /> (if purchased, complete separate HCA BPA) <br /> ❑ BlueEdge FSA(Vendor: ConnectYourCare) <br /> Outpatient Prescription Drugs: <br /> � Outpatient Prescription Drug Program <br /> � Covered under the medical benefit <br /> ❑ Dental Coverage <br /> � Blue Care Connection� <br /> � Stop Loss (if purchased, complete separate Exhibit to the Stop Loss Coverage Policy) <br /> ❑ Dearborn National Life Insurance (if purchased, complete separate Life application) <br /> ❑ HCSC COBRA Administrative Services (if purchased, complete separate COBRA Administrative Services <br /> Addendum to the BPA) <br /> ❑ Blue Directions (Private Exchange) (If selected, the Blue Directions Addendum is attached and made a part of <br /> the Policy.) <br /> Additional Comments: <br /> HCSC IL GEN ASO BPA(Rev. 5.15) page 4 <br />