Common use of I understand Clause in Contracts

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Enrollment Period, or an Initial Enrollment Period. Lives, or will be living, in the Blue MedicareRx service area on the effective date of coverage. Is a “new” client for Blue MedicareRx, defined as someone who is not an active Blue MedicareRx member. Additionally, the referral has not previously contacted Blue MedicareRx by phone to request information or an enrollment kit. Has accepted a Blue Referral Card** personalized with • the dedicated 800# • my agency name • my agency assigned number, and Follows required process to obtain information and enroll in Blue MedicareRx. ** A packet will be mailed to your agency shortly containing Blue MedicareRx Producer Referral Program Materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Referral Program Participation Agreement. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent E-Signature: Date: / / Subagent Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association under contract S5715 with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan with a Medicare contract.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Initial Enrollment Period, or an Initial a Special Enrollment Period. Period Lives, or will be living, in the Blue MedicareRx service area on the effective date of coverage. coverage Is a “new” client for Blue MedicareRx, defined as someone which is an individual who is not an active Blue MedicareRx member. Additionally, the referral has not previously contacted Blue MedicareRx by phone to request information or • information, • an enrollment kit. kit Has accepted a Blue Referral Card** personalized with • the dedicated 800# • my agency name or Agency name • my agency assigned number or Agency assigned number, and Follows the required process to obtain information and enroll in Blue MedicareRx. ** *A packet will be mailed to your agency you shortly containing Blue MedicareRx Producer Referral Program Materials materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Producer Referral Program Participation AgreementProgram. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent Producer E-Signature: Date: / / Subagent Producer Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association under contract S5715 with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan with a Medicare contract. 32210.1112 Blue MedicareRxSM 2013 Producer Referral Program EXHIBIT A – Referral Fee Schedule Payment is a one-time fee, for each referred and CMS-approved Blue MedicareRx member for which an enrollment application is received by the state indicated above Payment of fee will be made after receipt and allocation of an approved Member’s 3rd month’s premium and the member stays enrolled for 90 days There will be no charge backs resulting from a Member’s disenrollment after 90 days All fees due the Agency/Producer under this Schedule shall be contingent upon the Agency’s/Producer’s, and its employees or subcontractors (if applicable) compliance with the Blue MedicareRx Producer Referral Program rules and This fee schedule and terms will apply until a new fee schedule is issued by HCSC The payment fee schedule is in accordance with the guidelines of the Blue MedicareRx Producer Referral Program and is Exhibit A to the Producer Referral Agreement entered into between Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas and Agent/Producer. Because this program does not involve the Producer’s sale or marketing of the Blue MedicareRx plans, this Referral Fee is not a commission and is established and paid at the sole discretion of Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. This Referral Fee is subject to change and cancellation at any time. This referral fee is considered compensation as this term is defined by CMS and must comply with all CMS guidance and regulations regarding Medicare Part D compensation. This one-time Referral Fee is applicable to eligible client referrals that result in Blue MedicareRx enrollments that occur on or after the date above (subject to the receipt and approval of the Blue MedicareRx Producer Referral Participation Agreement and subject to the eligibility requirements outlined in such Agreement), and shall continue to be applicable to eligible referrals until the termination of the Producer Referral Program Participation Agreement or a new Blue MedicareRx Producer Referral Fee Schedule is issued by Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Product Name Payment Fee Blue MedicareRx One time Referral Fee $45 SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association under contract S5715 with the Centers for Medicare and Medicaid Services.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Enrollment Period, or an Initial Enrollment Period. Lives, or will be living, in the Blue MedicareRx service area on the effective date of coverage. Is a “new” client for Blue MedicareRx, defined as someone who is not an active Blue MedicareRx member. Additionally, the referral has not previously contacted Blue MedicareRx by phone to request information or an enrollment kit. Has accepted a Blue Referral Card** personalized with • the dedicated 800# • my agency name • my agency assigned number, and Follows required process to obtain information and enroll in Blue MedicareRx. ** A packet will be mailed to your agency shortly containing Blue MedicareRx Producer Referral Program Materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Referral Program Participation Agreement. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent E-Signature: Date: / / Subagent Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by Cross and Blue Shield of Texas refers to HCSC Insurance Services Company (HISC)Company, an Independent Licensee which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan with a Medicare contract.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Initial Enrollment Period, or an Initial a Special Enrollment Period. Period Lives, or will be living, in the Blue MedicareRx service area on the effective date of coverage. coverage Is a “new” client for Blue MedicareRx, defined as someone which is an individual who is not an active Blue MedicareRx member. Additionally, the referral has not previously contacted Blue MedicareRx by phone to request information or • information, • an enrollment kit. kit Has accepted a Blue Referral Card** personalized with • the dedicated 800# • my agency name or Agency name • my agency assigned number or Agency assigned number, and Follows the required process to obtain information and enroll in Blue MedicareRx. ** *A packet will be mailed to your agency you shortly containing Blue MedicareRx Producer Referral Program Materials materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Producer Referral Program Participation AgreementProgram. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent Producer E-Signature: Date: / / Subagent Producer Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association under contract S5715 with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan with a Medicare contract. 32210.0912 Blue MedicareRxSM 2013 Producer Referral Program EXHIBIT A – Referral Fee Schedule Payment is a one-time fee, for each referred and CMS-approved Blue MedicareRx member for which an enrollment application is received by the state indicated above Payment of fee will be made after receipt and allocation of an approved Member’s 3rd month’s premium and the member stays enrolled for 90 days There will be no charge backs resulting from a Member’s disenrollment after 90 days All fees due the Agency/Producer under this Schedule shall be contingent upon the Agency’s/Producer’s, and its employees or subcontractors (if applicable) compliance with the Blue MedicareRx Producer Referral Program rules and This fee schedule and terms will apply until a new fee schedule is issued by HCSC The payment fee schedule is in accordance with the guidelines of the Blue MedicareRx Producer Referral Program and is Exhibit A to the Producer Referral Agreement entered into between Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas and Agent/Producer. Because this program does not involve the Producer’s sale or marketing of the Blue MedicareRx plans, this Referral Fee is not a commission and is established and paid at the sole discretion of Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. This Referral Fee is subject to change and cancellation at any time. This referral fee is considered compensation as this term is defined by CMS and must comply with all CMS guidance and regulations regarding Medicare Part D compensation. This one-time Referral Fee is applicable to eligible client referrals that result in Blue MedicareRx enrollments that occur on or after the date above (subject to the receipt and approval of the Blue MedicareRx Producer Referral Participation Agreement and subject to the eligibility requirements outlined in such Agreement), and shall continue to be applicable to eligible referrals until the termination of the Producer Referral Program Participation Agreement or a new Blue MedicareRx Producer Referral Fee Schedule is issued by Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Product Name Payment Fee Blue MedicareRx One time Referral Fee $45 SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by HCSC Insurance Services Company (HISC), an Independent Licensee of the Blue Cross and Blue Shield Association under contract S5715 with the Centers for Medicare and Medicaid Services.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Medicare Advantage Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Enrollment Period, or an Initial Enrollment Period. Lives, or will be living, in the Blue MedicareRx Medicare Advantage service area on the effective date of coverage. Is a “new” client for Blue MedicareRxMedicare Advantage, defined as someone who is not an active Blue MedicareRx Medicare Advantage member. Additionally, the referral has not previously contacted Blue MedicareRx Medicare Advantage by phone to request information or an enrollment kit. Has accepted a Blue Medicare Advantage Referral Card** personalized with • the dedicated 800# • my agency name • my agency assigned number, and Follows required process to obtain information and enroll in Blue MedicareRxMedicare Advantage. ** A packet will be mailed to your agency shortly containing Blue MedicareRx Medicare Advantage Producer Referral Program Materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx Medicare Advantage plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Medicare Advantage Referral Program Participation Agreement. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent E-Signature: Date: / / Subagent Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx Medicare Advantage refers to Blue Medicare Advantage (PDPHMO), a Medicare Advantage HMO offered in Illinois and New Mexico by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC) is and Blue Medicare Advantage (PPO), a stand-alone prescription drug plan Medicare Advantage PPO offered in Texas by HCSC Insurance Services Company (HISC), an a wholly-owned subsidiary of HCSC. Both HCSC and HISC are Independent Licensee Licensees of the Blue Cross and Blue Shield Association and offer Medicare Advantage plans under contract S5715 Contracts H3822 (Illinois and New Mexico) and H1666 (Texas) with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan Both HCSC and HISC are Medicare Advantage organizations with a Medicare contract.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Enrollment Period, or an Initial Enrollment Period. Lives, or will be living, in the Blue MedicareRx service area on the effective date of coverage. Is a “new” client for Blue MedicareRx, defined as someone who is not an active Blue MedicareRx member. Additionally, the referral has not previously contacted Blue MedicareRx by phone to request information or an enrollment kit. Has accepted a Blue Referral Card** personalized with • the dedicated 800# • my agency name • my agency assigned number, and Follows required process to obtain information and enroll in Blue MedicareRx. ** A packet will be mailed to your agency shortly containing Blue MedicareRx Producer Referral Program Materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Referral Program Participation Agreement. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent E-Signature: Date: / / Subagent Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by Cross and Blue Shield of Illinois refers to HCSC Insurance Services Company (HISC)Company, an Independent Licensee which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan with a Medicare contract.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Initial Enrollment Period, or an Initial a Special Enrollment Period. Period Lives, or will be living, in the Blue MedicareRx service area on the effective date of coverage. coverage Is a “new” client for Blue MedicareRx, defined as someone which is an individual who is not an active Blue MedicareRx member. Additionally, the referral has not previously contacted Blue MedicareRx by phone to request information or • information, • an enrollment kit. kit Has accepted a Blue Referral Card** personalized with • the dedicated 800# • my agency name or Agency name • my agency assigned number or Agency assigned number, and Follows the required process to obtain information and enroll in Blue MedicareRx. ** *A packet will be mailed to your agency you shortly containing Blue MedicareRx Producer Referral Program Materials materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Producer Referral Program Participation AgreementProgram. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent Producer E-Signature: Date: / / Subagent Producer Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by Cross and Blue Shield of Texas refers to HCSC Insurance Services Company (HISC)Company, an Independent Licensee which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan with a Medicare contract. 54891.0811 Blue MedicareRxSM 2012 Producer Referral Program EXHIBIT A – Referral Fee Schedule Payment is a one-time fee, for each referred and CMS-approved Blue MedicareRx member for which an enrollment application is received by the state indicated above Payment of fee will be made after receipt and allocation of an approved Member’s 3rd month’s premium and the member stays enrolled for 90 days There will be no charge backs resulting from a Member’s disenrollment after 90 days All fees due the Agency/Producer under this Schedule shall be contingent upon the Agency’s/Producer’s, and its employees or subcontractors (if applicable) compliance with the Blue MedicareRx Producer Referral Program rules and This fee schedule and terms will apply until a new fee schedule is issued by HCSC The payment fee schedule is in accordance with the guidelines of the Blue MedicareRx Producer Referral Program and is Exhibit A to the Producer Referral Agreement entered into between Blue Cross and Blue Shield of Texas and Agent/Producer. Because this program does not involve the Producer’s sale or marketing of the Blue MedicareRx plans, this Referral Fee is not a commission and is established and paid at the sole discretion of Blue Cross and Blue Shield of Texas. This Referral Fee is subject to change and cancellation at any time. This referral fee is considered compensation as this term is defined by CMS and must comply with all CMS guidance and regulations regarding Medicare Part D compensation. This one-time Referral Fee is applicable to eligible client referrals that result in Blue MedicareRx enrollments that occur on or after the date above (subject to the receipt and approval of the Blue MedicareRx Producer Referral Participation Agreement and subject to the eligibility requirements outlined in such Agreement), and shall continue to be applicable to eligible referrals until the termination of the Producer Referral Program Participation Agreement or a new Blue MedicareRx Producer Referral Fee Schedule is issued by Blue Cross and Blue Shield of Texas. Product Name Payment Fee Blue MedicareRx One time Referral Fee $45 SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue Cross and Blue Shield of Texas refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Medicare Advantage Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Enrollment Period, or an Initial Enrollment Period. Lives, or will be living, in the Blue MedicareRx Medicare Advantage service area on the effective date of coverage. Is a “new” client for Blue MedicareRxMedicare Advantage, defined as someone who is not an active Blue MedicareRx Medicare Advantage member. Additionally, the referral has not previously contacted Blue MedicareRx Medicare Advantage by phone to request information or an enrollment kit. Has accepted a Blue Medicare Advantage Referral Card** personalized with • the dedicated 800# • my agency name • my agency assigned number, and Follows required process to obtain information and enroll in Blue MedicareRxMedicare Advantage. ** A packet will be mailed to your agency shortly containing Blue MedicareRx Medicare Advantage Producer Referral Program Materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx Medicare Advantage plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Medicare Advantage Referral Program Participation Agreement. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent E-Signature: Date: / / Subagent Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx Medicare Advantage refers to Blue Medicare Advantage (PDPHMO), a Medicare Advantage HMO offered in Illinois and New Mexico by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC) is and Blue Medicare Advantage (PPO), a stand-alone prescription drug plan Medicare Advantage PPO offered in Texas by HCSC Insurance Services Company (HISC), an a wholly-owned subsidiary of HCSC. Both HCSC and HISC are Independent Licensee Licensees of the Blue Cross and Blue Shield Association and offer Medicare Advantage plans under contract S5715 Contracts H3822 (Illinois and New Mexico) and H1666 (Texas) with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan Both HCSC and HISC are Medicare Advantage organizations with a Medicare contract.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Initial Enrollment Period, or an Initial a Special Enrollment Period. Period Lives, or will be living, in the Blue MedicareRx service area on the effective date of coverage. coverage Is a “new” client for Blue MedicareRx, defined as someone which is an individual who is not an active Blue MedicareRx member. Additionally, the referral has not previously contacted Blue MedicareRx by phone to request information or • information, • an enrollment kit. kit Has accepted a Blue Referral Card** personalized with • the dedicated 800# • my agency name or Agency name • my agency assigned number or Agency assigned number, and Follows the required process to obtain information and enroll in Blue MedicareRx. ** *A packet will be mailed to your agency you shortly containing Blue MedicareRx Producer Referral Program Materials materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Producer Referral Program Participation AgreementProgram. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent Producer E-Signature: Date: / / Subagent Producer Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by Cross and Blue Shield of New Mexico refers to HCSC Insurance Services Company (HISC)Company, an Independent Licensee which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan with a Medicare contract. 81950.0811 Blue MedicareRxSM 2012 Producer Referral Program EXHIBIT A – Referral Fee Schedule Payment is a one-time fee, for each referred and CMS-approved Blue MedicareRx member for which an enrollment application is received by the state indicated above Payment of fee will be made after receipt and allocation of an approved Member’s 3rd month’s premium and the member stays enrolled for 90 days There will be no charge backs resulting from a Member’s disenrollment after 90 days All fees due the Agency/Producer under this Schedule shall be contingent upon the Agency’s/Producer’s, and its employees or subcontractors (if applicable) compliance with the Blue MedicareRx Producer Referral Program rules and This fee schedule and terms will apply until a new fee schedule is issued by HCSC The payment fee schedule is in accordance with the guidelines of the Blue MedicareRx Producer Referral Program and is Exhibit A to the Producer Referral Agreement entered into between Blue Cross and Blue Shield of New Mexico and Agent/Producer. Because this program does not involve the Producer’s sale or marketing of the Blue MedicareRx plans, this Referral Fee is not a commission and is established and paid at the sole discretion of Blue Cross and Blue Shield of New Mexico. This Referral Fee is subject to change and cancellation at any time. This referral fee is considered compensation as this term is defined by CMS and must comply with all CMS guidance and regulations regarding Medicare Part D compensation. This one-time Referral Fee is applicable to eligible client referrals that result in Blue MedicareRx enrollments that occur on or after the date above (subject to the receipt and approval of the Blue MedicareRx Producer Referral Participation Agreement and subject to the eligibility requirements outlined in such Agreement), and shall continue to be applicable to eligible referrals until the termination of the Producer Referral Program Participation Agreement or a new Blue MedicareRx Producer Referral Fee Schedule is issued by Blue Cross and Blue Shield of New Mexico. Product Name Payment Fee Blue MedicareRx One time Referral Fee $45 SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue Cross and Blue Shield of New Mexico refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services.

I understand. The terms of this agreement are subject to change upon written notice to my Agency by HCSC, and may be terminated at any time and for any reason by either my Agency or HCSC. This agreement will be automatically updated by HCSC at its discretion based on changes to applicable laws, regulation, and/or changes to HCSC policies and procedures. This agreement will be automatically terminated upon my completing certification to sell Blue MedicareRx plans or my Agency completing the applicable Medicare Amendment as part of the certification requirements to sell Blue MedicareRx plans for Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas. Consistent with CMS Marketing guidelines, if I was previously certified and receiving renewal compensation from my Agency, and I choose to participate in the Blue MedicareRx Referral Program, and thereby elect to discontinue my certification to sell Blue MedicareRx, any future renewal compensation from sales effective January 1, 2009 or later will be forfeited. I will comply with the HIPAA Business Associate provisions in my Agency’s HCSC Producer Agreement that is applicable to any Protected Health Information (PHI) or Sensitive Personal Information (SPI) handled under this program. Prospect Eligibility Terms I understand that eligibility for referral under the Blue MedicareRx Referral Program is an individual who Is eligible to enroll during an Annual Enrollment Period, Special Initial Enrollment Period, or an Initial a Special Enrollment Period. Period Lives, or will be living, in the Blue MedicareRx service area on the effective date of coverage. coverage Is a “new” client for Blue MedicareRx, defined as someone which is an individual who is not an active Blue MedicareRx member. Additionally, the referral has not previously contacted Blue MedicareRx by phone to request information or • information, • an enrollment kit. kit Has accepted a Blue Referral Card** personalized with • the dedicated 800# • my agency name or Agency name • my agency assigned number or Agency assigned number, and Follows the required process to obtain information and enroll in Blue MedicareRx. ** *A packet will be mailed to your agency you shortly containing Blue MedicareRx Producer Referral Program Materials materials and a supply of personalized referral cards. This packet will serve as our acknowledgement of your participation. Attestation I understand that a referral expressing interest in a Blue MedicareRx plan has choices and that not all referrals provided will result in an enrollment. I agree to comply with the Terms and Conditions of the Blue MedicareRx Producer Referral Program Participation AgreementProgram. I understand that violation of any part of the Participation Agreement may result in termination from the program. Subagent Producer E-Signature: Date: / / Subagent Producer Email Address: After filling out this Participation Form, please click on the Submit button below. [This will automatically send your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx] Submit You can also e-mail your completed Participation Form to: Xxxxxxxx_Xxxxxxxxx@xxxxxx.xxx Thank you for your participation. Please retain a copy of this form for your records. SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue MedicareRx (PDP) is a stand-alone prescription drug plan offered by Cross and Blue Shield of Illinois refers to HCSC Insurance Services Company (HISC)Company, an Independent Licensee which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services. A stand-alone prescription drug plan with a Medicare contract. 32210.1011 Blue MedicareRxSM 2012 Producer Referral Program EXHIBIT A – Referral Fee Schedule Payment is a one-time fee, for each referred and CMS-approved Blue MedicareRx member for which an enrollment application is received by the state indicated above Payment of fee will be made after receipt and allocation of an approved Member’s 3rd month’s premium and the member stays enrolled for 90 days There will be no charge backs resulting from a Member’s disenrollment after 90 days All fees due the Agency/Producer under this Schedule shall be contingent upon the Agency’s/Producer’s, and its employees or subcontractors (if applicable) compliance with the Blue MedicareRx Producer Referral Program rules and This fee schedule and terms will apply until a new fee schedule is issued by HCSC The payment fee schedule is in accordance with the guidelines of the Blue MedicareRx Producer Referral Program and is Exhibit A to the Producer Referral Agreement entered into between Blue Cross and Blue Shield of Illinois and Agent/Producer. Because this program does not involve the Producer’s sale or marketing of the Blue MedicareRx plans, this Referral Fee is not a commission and is established and paid at the sole discretion of Blue Cross and Blue Shield of Illinois. This Referral Fee is subject to change and cancellation at any time. This referral fee is considered compensation as this term is defined by CMS and must comply with all CMS guidance and regulations regarding Medicare Part D compensation. This one-time Referral Fee is applicable to eligible client referrals that result in Blue MedicareRx enrollments that occur on or after the date above (subject to the receipt and approval of the Blue MedicareRx Producer Referral Participation Agreement and subject to the eligibility requirements outlined in such Agreement), and shall continue to be applicable to eligible referrals until the termination of the Producer Referral Program Participation Agreement or a new Blue MedicareRx Producer Referral Fee Schedule is issued by Blue Cross and Blue Shield of Illinois. Product Name Payment Fee Blue MedicareRx One time Referral Fee $45 SM Service Xxxx of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans ® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans Blue Cross and Blue Shield of Illinois refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services.