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List Service: <br /> Other: Select Service Category $ $ $ $ <br /> List Service: <br /> Other: Select Service Category $ $ $ $ <br /> List Service: <br /> Other: Select Service Category � $ $ $ <br /> List Service: <br /> Miscellaneous: $ $ $ $ <br /> Miscellaneous: $ $ $ g <br /> Total $35.95 $ $ $ <br /> *Prescription Drug Rebate Credit per Covered Employee per month is the guaranteed Prescription Drug Rebate savings <br /> reflected as a Prescription Drug Rebate credit. Expected rebate amounts to be received by the Claim Administrator are <br /> passed back to the Employer with one hundred percent(100%)of the expected amount applied as a credit on the monthly <br /> billing statement on a per Covered Employee per month basis. Rebate credits are paid prospectively to the Employer and <br /> shall not continue after termination of the Prescription Drug Program. (Further information concerning this credit is <br /> included in the governing Administrative Services Agreement ("AgreemenY') to which this ASO BPA is attached under the <br /> section titled "CLAIM ADMINISTRATOR'S SEPARATE FINANCIAL ARRANGEMENTS WITH PHARMACY BENEFIT <br /> MANAGERS.") <br /> Administrative Line Item Charges Frequency Amount <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 /> Total: �_ <br /> Note: Additional services and/or fees may be itemized in the "Miscellaneous"fields above or in the Additional Comments <br /> section below. <br /> Legacy Carve Out Disease Management: Not applicable <br /> Additional Comments(Provide any additional details regarding the fee structure): <br /> Claim Administrator Provider Access Fee(s) <br /> � NO CHANGES ❑ SEE ADDITIONAL PROVISIONS <br /> Group Number(s): P22346-P22347-P22348-P22349 <br /> � %of ADP Savings: 1.57% <br /> ❑ $ per Covered Employee per month: $ <br /> Comp/ete for Groups with mu/tip/e ProviderAccess Fees by products(i.e., CMM, PPO and/or POS p/ans): <br /> Grou Number s : <br /> ❑ % of ADP Savings: % <br /> ❑ $per Covered Employee per month: $ <br /> HCSC IL GEN ASO BPA(Rev. 5.15) page 6 <br />