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Administrative Services <br />Fees <br />Initial Determinations and Level One Appeals for the <br />No Charge <br />Benefit Review Program, consisting of reviews <br />$3.00 per claim <br />known as: <br />$3.00 per claim <br />Plan Design Related Requests <br />$0.32 / PMPM of Elected <br />Plan Exclusion Reviews (clinical or <br />$0.03 / PMPM of Elected <br />administrative reviews of non -Covered Drugs) <br />Copay Reviews <br />$0.10 PMPM per combined accumulator up to <br />Plan Limit Reviews (e.g. age, gender, days' <br />maximum of $0.20 PMPM for existing <br />supply limits) <br />connection with medical carrier or TPA. <br />Plan Rule/Administrative Reviews/Non-clinical <br />Fees to establish connection with new medical <br />Reviews <br />carrier or TPA are quoted upon request. <br />Clinical Benefit Reviews <br />Direct Claim Reject Reviews <br />Final and Binding Appeals — Level Two Appeals * <br />No Charge <br />and/or Urgent Appeals** <br />*Level One for clients with only one level of <br />appeal <br />20% of audit recoveries <br />** Appeals can be urgent at Level One or Level <br />Two and decisions are final and binding. <br />External Reviews by Independent Review <br />No Charge <br />Organizations - for non -grandfathered plans <br />PBM Services <br />Fees <br />Advanced Utilization Management AUM Bundle <br />$0.46 / PMPM <br />Member -submitted paper claims processing fee <br />$3.00 per claim <br />Medicaid subrogation claims fee <br />$3.00 per claim <br />O ioid Program <br />$0.32 / PMPM of Elected <br />ACA Statin "Trend Management" Program <br />$0.03 / PMPM of Elected <br />Combined Benefit Management <br />Services to manage combined medical -pharmacy <br />$0.10 PMPM per combined accumulator up to <br />benefits that are not a consumer -directed health <br />maximum of $0.20 PMPM for existing <br />(CDH) plan. <br />connection with medical carrier or TPA. <br />Services include ongoing management of the data <br />Fees to establish connection with new medical <br />exchange platform with the medical vendor/TPA, <br />carrier or TPA are quoted upon request. <br />production monitoring. and quality control, and <br />designated operations team. Combined benefit types <br />may include deductible, out of pocket, spending <br />account, and lifetime maximum. <br />Network Pharmacy Services <br />Network Pharmacy Audit Program <br />20% of audit recoveries <br />Comprehensive Consumer Driven Health (CDH) <br />Solution <br />Consumer Choice Plan - Technical <br />$0.35 PMPM <br />• Bi-directional data exchange; dedicated <br />*these charges would be in addition to any pricing <br />operations; 24-hour a day, seven -days a week <br />adjustments if greater than ten percent of Client's total <br />monitoring and quality control; performance <br />utilization for all Plans is attributable to a CDHC. <br />reporting; and analytics <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETAR2 <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />