2020-241A - Laserfiche WebLink

Home Browse Search

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