Network PHARMACY is a retail, mail order or specialty pharmacy that has a contract to accept our pharmacy allowance for prescription drugs and diabetic equipment or supplies covered under this plan. NETWORK PROVIDER is a provider that has entered into a contract with us or other Blue Cross and Blue Shield plans. For pediatric dental care services, network provider is a dentist that has entered into a contract with us or participates in the Dental Coast to Coast Network. For pediatric vision hardware services, a network provider is a provider that has entered into a contract with EyeMed, our vision care service manager.
XXXXXXX COMPANY By: ____________________________________ Name: Title: The undersigned hereby acknowledges receipt of an executed original of this Agreement, together with a copy of the prospectus for the Plan, dated ________, summarizing key provisions of the Plan, and accepts the award of the Restricted Stock granted hereunder on the terms and conditions set forth herein and in the Plan. Date: ______________________ Grantee: