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DocuSign Envelope ID: 5B185859-5943-4C41-90BF-OCE5E90FDADD <br />(01/2021 Version) <br />PBM Services – No Additional <br />Customer service for Members Electronic claims processing <br />Electronic/on-line eligibility submission Plan setup <br />Standard coordination of benefits (COB) Software training for access to our on-line <br />reject for primary carrier system(s) <br />FSA eligibility feeds <br />A. Network Pharmacy Services <br />help desk <br />Pharmacy reimbursement <br />-Pharmacy <br />Pharmacy network management <br />Network development (uponrequest) <br />B. Home Delivery Services <br />Benefit education <br />Prescription delivery – standard <br />Web -based client reporting – <br />Annual Strategic Account Plan report <br />Ad-hoc desktop parametric reports <br />B i I I i ng reports <br />Claims detail extract file electronic CPDP format <br />Inquiry access to claims processing system <br />Load 12 months claims history for clinical reports and <br />r!porting <br />Website Services <br />Express-Scripts.com for Members — access to benefit, <br />drug, health and wellness information; prescription <br />ordering ca abili • and customer service <br />Iniplenientation Package and Member Communications <br />• New Member packets (includes two standard resin ID <br />cards) <br />■ Member replacement cards printed via web (For hard- <br />cards charges are passed through from the PBM <br />-copy <br />• Member -requested replacement packets or Client <br />S 1.50 + postage per packet or card <br />requested re -carding <br />Concurrent Drug Utilization Review (DUR) <br />No Charge <br />Overrides <br />a. Sponsor -requested overrides <br />b. Lost/stolen overrides <br />c. Vacation supplies <br />2.2 Administrator Clinical Proerams <br />If elected, the Low Clinical Value ("LCV") exclusion option prevents unnecessary spending by <br />removing LCV medications from the formulary without impact to client rebates while providing equal <br />or more effective medicines at a lower cost. LCV medications are drugs that treat common conditions <br />that do not provide any additional or superior therapeutic value when compared to currently existing <br />therapies already in the marketplace. These medications are excluded in addition to any products that <br />would normally be excluded by PBM Formulary. This exclusion occurs without affecting rebate <br />minimum guarantees or contracted discount rates. Administrator reserves the right to amend, from time <br />to time, the list of low clinical value medications. The list of low clinical value medications may be <br />updated quarterly. Client may request a current list of LCV medications. <br />■ If elected, Administrator's High Dollar Claim Review, Prior Authorization and Appeals program <br />("HDCR"), will provide Client with umbrella protection against high-cost prescription claims for approved <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF EXPRESS SCRIPTS AND RXBENEFITS <br />C. <br />