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DocuSign Envelope ID: 5B185859-5943-4C41-90BF-OCE5E90FDAD D (01/2021 Version) 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 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 Advantage Program individual j2rices listed in table below $1.45 Lier claim Manufacturer Copa.N Assistance Programs 1, evs Not Elected • Out of Pocket Protection Accumulation • Out of Pocket Protection + Variable Copay Not Elected Assistance Program • SaveOnSP Not Elected • Out of Pocket Protection + SaveOnSP $0A0 per claim (Elected) Reviewspp • Low Clinical Value Exclusions LC $0.30 per claim (Elected) • High Dollar Claim Review HDCR $0.75 per claim (Elected) 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 Step Therapy Included in the existing PA charge of $55 Drug Quantity Management per initial determination „ 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. Final and Binding Appeals — Level Two Appeals and/or $10.00 per review* Urgent Appeals for UM, formulary, and benefit reviews. OR No Charge if Client elects HDCR External Reviews by Independent Review Organizations - for $800 per review non -grandfathered plans OR No Charge if Client elects HDCR Third Party Integration Fees Charges passed through from provider or mutually agreed upon by Parties The following terms and conditions apply only if client does not elect HDCR: ■ Initial determination — this is the first review of drug coverage based on the plan's conditions of coverage. Initial determinations are also referred to as initial reviews, coverage reviews, prior authorization reviews, UM reviews, or benefit reviews. ■ The Level 2 and Urgent Appeal Service is an optional service for Clients to enroll in and there is an incremental fee of $10 per initial determination. ■ Level 2 and Urgent Appeals are not included in the UM package fees. ■ The Level 2 and Urgent Appeal Service fee is not charged per appeal. It is charged for each initial review. This allows Client to better estimate their appeal costs since it is based on the number of NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF EXPRESS SCRIPPS AND RXBENEFITS