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Administrative Services <br />Fees <br />Initial Determinations and Level One Appeals for the <br />$55 per review <br />Benefit Review Program, consisting of reviews known as: <br />$10.00 <br />Plan Design Related Requests <br />$3.00 per claim <br />Plan Exclusion Reviews (clinical or administrative <br />$3.00 per claim <br />reviews of non -Covered Drugs) <br />$0.32 / PMPM If Elected <br />Copay Reviews <br />$0.03 / PMPM f Elected <br />Plan Limit Reviews (e.g. age, gender, days' supply <br />Services to manage combined medical -pharmacy benefits <br />limits) <br />that are not a consumer -directed health (CDH) plan. <br />Plan Rule/Administrative Reviews/Non-clinical <br />Services include ongoing management of the data exchange <br />Reviews <br />platform with the medical vendor/TPA, production <br />Clinical Benefit Reviews <br />monitoring and quality control, and designated operations <br />Direct Claim Reject Reviews <br />team. Combined benefit types may include deductible, out <br />Final and Binding Appeals — Level Two Appeals * and/or <br />$0.00 per review* (incremental to PMPM fees <br />Urgent Appeals** <br />or the per review fees above) <br />*Level One for clients with only one level of appeal <br />* This additional fee is applied to each <br />** Appeals can be urgent at Level One or Level Two <br />initial determination. <br />and decisions are final and binding. <br />External Reviews by Independent Review Organizations -for <br />F$_l00 per review <br />non -grandfathered plans <br />PBM Services <br />Fees <br />Advanced Utilization Manag ement (AUM Bundle <br />$0.51 / PMPM <br />Manual/hardcopy eligibility submission <br />$10.00 <br />Member -submitted paper claims processing fee <br />$3.00 per claim <br />Medicaid subrogation claims fee <br />$3.00 per claim <br />Opioid Program <br />$0.32 / PMPM If Elected <br />ACA Statin "Trend Management" Program <br />$0.03 / PMPM f Elected <br />Combined Benefit Management <br />Services to manage combined medical -pharmacy benefits <br />$0.10 PMPM per combined accumulator up to <br />that are not a consumer -directed health (CDH) plan. <br />maximum of $0.20 PMPM for existing <br />Services include ongoing management of the data exchange <br />connection with medical carrier or TPA. <br />platform with the medical vendor/TPA, production <br />monitoring and quality control, and designated operations <br />Fees to establish connection with new medical <br />team. Combined benefit types may include deductible, out <br />carrier or TPA are quoted upon request. <br />of ocket, spending account and lifetime maximum. <br />Network Pharmacy Services <br />Network Pharmacy Audit Program 20% of audit recoveries <br />67 <br />