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DocuSign Envelope ID. 513185859-5943-4C41-90BF-0CE5E90FDADD <br />(01/2021 Version) <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 <br />a 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 <br />are incurred when cases are appealed. <br />Appeals can be deemed urgent at Level 1 or Level 2. Urgent appeal decisions are final and <br />binding. If a Level 1 Appeal is processed as urgent, there is no Level 2 appeal. <br />PBM Services <br />1ccs <br />Advanced Utilization Management (AUM Bundle) <br />$0.46 / PMPM or Passed through from <br />PBM <br />Member -submitted paper claims processing fee <br />$3.00 per claim <br />Medicaid or Medicare subrogation claims fee <br />$3.00 per claim <br />-Opioid Program <br />$0.32 / PMPM If Elected <br />ACA Statin "Trend Management" Program <br />1 $0.03 / PMPM If Elected <br />Combined Benefit Management <br />Services to manage combined medical -pharmacy benefits <br />$0.10 PMPM per combined accumulator up <br />that are not a consumer -directed health (CDH) plan. <br />to 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 <br />team. Combined benefit types may include deductible, out <br />medical carrier or TPA are quoted upon <br />of pocket, spending account, and lifetime maximum. <br />request. <br />Network Pharmacy <br />Network Pharmacy Audit Pro <br />20% of audit recoveries <br />Technical $0.48 PMPM <br />Bi-directional data exchange; dedicated operations; 24-hour <br />a day, seven -days a week monitoring and quality control; *these charges would be in addition to any <br />performance reporting; and analytics <br />pricing adjustments if greater than ten <br />Decision Support percent of Client's total utilization for all <br />Dedicated CDH member services, Prescription Benefit Plans is attributable to a CDHC. <br />Review Statements, Retail Pricing Transparency <br />Member Adherence <br />ScreenRx <br />Preventive Medications <br />Member Education <br />Proactive, personalized member communications open <br />enrollment tools and member communications library, <br />robust online features, and preventive care proactive, <br />personalized member communications <br />ScreenRx for PPO Plans <br />$0.25 PMPM (If Elected) <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF EXPRESS SCRIPTS AND RXBENEFITS <br />