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C. SERVICES: FORMULARY. <br />1. Base Administrative Services: The following services are the base administrative services made available to <br />Client and its Members pursuant to the Agreement (including this Exhibit A) (the "Base Administrative <br />Services'), as applicable: <br />• Administration of eligibility submitted via tape or telecommunication <br />• Eligibility maintenance <br />• Client support system for on-line access to current eligibility <br />• Administration of Client's Plan Design <br />• In -network claims adjudication via on-line claims adjudication system <br />• Designated Account Team <br />• Client clinical and plan consulting, analysis and cost projections <br />• Annual analysis of program utilization and impact of plan design and managed care interventions <br />• Welcome Package and ID Cards for new Members <br />• Standard Member communications <br />• Toll-free telephone access to customer service for the program for use by Members and Client's <br />benefits personnel and representatives <br />2. Additional Administrative Services: Client will pay for additional administrative services (the "Additional <br />Administrative Services") beyond those included in the Base Administrative Services that are requested by <br />Client and provided or made available by Administrator under the program as follows: <br />2.1 Administrative Fees <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND <br />CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />3 <br />Fees_,"ffW1.,, <br />Administrative Services <br />Transaction Fees Payable for Administrative Services (per <br />$0.65 per Prescription Drug Claim made <br />Article IV.B of the Agreement) <br />by Members payable on a bi-monthlybasis <br />Transaction Fees Payable for Administrator's Clinical <br />$1.45 per claim <br />Advantage Program <br />individual nrices listed in table below <br />Fees <br />Copay Assistance Programs <br />• Out of Pocket Protection Accumulation <br />Not Elected <br />• Out of Pocket Protection + Variable Copay <br />Not Elected <br />Assistance Program <br />• SaveOnSP <br />Not Elected <br />• Out of Pocket Protection + SaveOnSP <br />$0.40 per claim <br />50.30 per claim <br />RevieiNs and Appeals Management <br />• Low Clinical Value Exclusions (LCN') <br />• High Dollar Claim Review (HDCR) <br />50.75 per claim <br />Initial Determinations (i.e. coverage reviews) and Level <br />Included in the existing utilization <br />One Non -Urgent Appeals for the Coverage Authorization <br />management PMPM charge <br />Program, consisting of: <br />OR <br />Prior Authorization <br />Included in the existing PA charge of $55 <br />Step Therapy <br />per initial determination * <br />Drug Quantity Management <br />OR <br />No Charge if Client elects HDCR <br />Initial Determinations and Level One Non -Urgent Appeals <br />$55 per initial determination <br />for benefit reviews. Examples: copay review, plan <br />OR <br />excluded drug coverage review, administrative plan design <br />No Charge if Client elects HDCR <br />review. <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND <br />CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />3 <br />