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PBM Services <br />Fees <br />Final and Binding Appeals — Level Two Appeals * and/or <br />$0.00 per review* (incremental to PMPM fees or per <br />Urgent Appeals** <br />review fees above) <br />*Level One for clients with only one level of appeal <br />* this additional fee is applied to each initial <br />** Appeals can be urgent at Level One or Level Two <br />determination. <br />and decisions are final and binding. <br />External Reviews by Independent Review Organization's - <br />$800 per review <br />for non -grandfathered plans <br />Comprehensive Consumer Driven Health (CDH) <br />Solution <br />Consumer Choice Plan <br />All services: $0.65 PMPM <br />Technical <br />Technical and Member Advocacy: $0.35 PMPM <br />Bi-directional data exchange; dedicated operations; 24- <br />Health Choices and Drug Choices: $0.30 PMPM <br />hour a day, seven -days a week monitoring and quality <br />control; performance reporting; and analytics <br />Member Advocacy <br />*these charges would be in addition to any pricing <br />Dedicated CDH member services, open enrollment tools <br />adjustments if greater than ten percent of Client's total <br />and member communications library, robust online <br />utilization for all Plans is attributable to a CDHC. <br />features, and preventive care <br />Health Choices <br />Medication Adherence Monitoring and Outreach and <br />proactive, personalized member communications <br />Drug Choices <br />Benefit Coaching, Prescription Benefit Review <br />Statements, proactive, personalized member <br />communications <br />Medicare Part D — Retiree Drug Subsidy S <br />Part D subsidy enhanced service (EST sends reports to <br />$1.12 PMPM for Medicare -qualified Members with a <br />CMS on behalf of Client) <br />minimum annual fee of $7,500, <br />i Notice of Creditable Coverage <br />$1.35/letter + postage <br />Part D Subsidy standard service (ESI sends reports to <br />$0.62 PMPM for Medicare -qualified Members with a <br />Client) <br />minimum annual fee of $5,000 <br />$1.35/letter + postage <br />A. Notice of Creditable Coverage <br />3. Pricing. The financial terms set forth are conditioned on such exclusive arrangement and all other specified <br />conditions set forth in Exhibit A of the Agreement. Client will pay to Administrator the amounts set forth below, net <br />of applicable Copayments. The application of brand and generic pricing below may be subject to certain "dispensed <br />as written" (DAW) protocols and Client defined plan design and coverage policies for adjudication and Member <br />Copayment purposes. Sales or excise tax or other governmental surcharge, if any, will be the responsibility of Client. <br />Members will always pay based on the logic below: <br />Retail: Lowest of (i) the U&C price, (ii) Plan copayments/coinsurance, or (iii) discounted AWP (including MAC <br />price, when MAC pricing is applicable). <br />Mail Order: Lower of (i) Plan copayments/coinsurance or (ii) discounted AWP (including MAC price, when <br />MAC pricing is applicable). <br />3.1 Pricing Guarantees. <br />(a) Ingredient Cost Guarantee. ESI will guarantee an average aggregate annual discount as reflected <br />below on Client utilization to be calculated as follows: <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />22 <br />