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FEE SCHEDULE <br /> Payment Specifications <br /> � NO CHANGES ❑ SEE ADDITIONAL PROVISIONS <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 <br /> � Monthly <br /> ❑ Other(please specify) <br /> Claim Settlement Period: � Monthly ❑Other(please specify) <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 /> Final Settlement: Final Settlement is to be made within 60 days after end of Run-Off Period. <br /> Standard is sixty(60) days. <br /> Fee Schedule Period <br /> To begin on Effective Date of Coverage and continue for: <br /> � 12 Months ❑ Other(please specify): Months <br /> Administrative Charge(s) <br /> ❑ NO CHANGES ❑ SEE ADDITIONAL PROVISIONS <br /> �Applies to all coverages <br /> ❑ Different percentage(s) or amount(s)for the following types of coverages. Please specify: <br /> Subscriber Share Methodology for Illinois Network Provider Claims Applies: � Yes ❑ No <br /> (If no,a letter declining Subscriber Share Methodology for Claims processing must be attached to this Benefit Program Application.) <br /> Administrative Charge Chart: <br /> Each column can be used to differentiate rates between product types or employee tiers. All columns do not need to be <br /> used.All fees listed are per employee per month. <br /> Administrative Per Employee per Month (PEPM) Charges <br /> roduct/Service PPO <br /> Administrative Fee $55.05 $ $ $ <br /> Commissions $Net of <br /> commissions $ $ $ <br /> Dental $ $ $ $ <br /> Fiduciary $ $ $ $ <br /> Rx Administrative Fee $ $ $ $ <br /> *Prescription Drug Rebate Credit $-19.10 $ $ $ <br /> Other: Select Service Category $ $ $ $ <br /> HCSC IL GEN ASO BPA(Rev. 5.15) page 5 <br />