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Additional Reviews for Initial Determinations (only <br />$70.00 per review (incremental to initial <br />applicable if client does not elect HDCR): <br />determination fees above) <br />Additional review that require obtaining and reviewing <br />medical records/chart notes by a provider, including but not <br />limited to a nurse or pharmacist <br />Final and Binding Appeals — Level Two Appeals and/or <br />$10.00 per review* <br />Urgent Appeals for UM, formulary, and benefit reviews. <br />OR <br />No Charge if Client elects HDCR <br />External Reviews by Independent Review Organizations - for <br />$800 per review <br />non -grandfathered plans <br />OR <br />No Charge if Client elects HDCR <br />The following terms and conditions apply only if client does not elect HDCR: <br />■ Initial determination — this is the first review of drug coverage based on the plan's conditions of <br />coverage. Initial determinations are also referred to as initial reviews, coverage reviews, prior <br />authorization reviews, UM reviews, or benefit reviews. <br />■ The Level 2 and Urgent Appeal Service is an optional service for Clients to enroll in and there is an <br />incremental fee of $10 per initial determination. <br />■ Level 2 and Urgent Appeals are not included in the UM package fees. <br />■ The Level 2 and Urgent Appeal Service fee is not charged per appeal. It is charged for each initial <br />review. This allows Client to better estimate their appeal costs since it is based on the number of <br />initial determinations. The fees cover the legal and operational costs involved with handling final <br />and binding appeal reviews, which includes, but is not limited to the following: staffing of clinical <br />professionals and supportive personnel, notifications to patients and prescribers, and maintaining a <br />process aligned with state and Federal regulations. <br />• Charges for the Level 2 and Urgent Appeal Service are billed on the monthly admin invoice for <br />completed initial determination for UM, formulary, and benefit reviews. No subsequent charges are <br />incurred when cases are appealed. <br />■ Appeals can be deemed urgent at Level 1 or Level 2. Urgent appeal decisions are final and binding. <br />If a Level 1 Appeal is processed as urgent, there is no Level 2 appeal. <br />Advanced Utilization Management AUM Bundle $0.46 / PMPM <br />Member -submitted paper claims processing fee $3.00 per claim <br />Medicaid subrogation claims fee $3.00 per claim <br />Opioid Program $0.32 / PMPM of Elected <br />ACA Statin "Trend Manaaement" Proeram $0.03 / PMPM (Not Elected) <br />Services to manage combined medical -pharmacy benefits <br />that are not a consumer -directed health (CDH) plan. <br />Services include ongoing management of the data exchange <br />platform with the medical vendor/TPA, production <br />monitoring and quality control, and designated operations <br />team. Combined benefit types may include deductible, out of <br />pocket, spending account, and lifetime maximum. <br />Network Pharmacy Audit <br />$0.10 PMPM per combined accumulator up <br />to maximum of $0.20 PMPM for existing <br />connection with medical carrier or TPA. <br />Fees to establish connection with new <br />medical carrier or TPA are quoted upon <br />request. <br />20% of audit recoveries <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND <br />CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />4 <br />