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DocuSign Envelope ID: 5B185859-5943-4C41-90BF-OCE5E90FDAD D <br />(01/2021 Version) <br />Additional Administrative Services: Client will pay for additional administrative services (the "Additional <br />Administrative Services") beyond those included in the Base Administrative Services that are requested by <br />Client and provided or made available by Administrator under the program as follows: <br />2.1 Administrative Fees <br />The following terms and conditions apply only if client does not elect HDCR: <br />■ Initial determination — this is the first review of drug coverage based on the plan's conditions of <br />coverage. Initial determinations are also referred to as initial reviews, coverage reviews, prior <br />authorization reviews, UM reviews, or benefit reviews. <br />■ The Level 2 and Urgent Appeal Service is an optional service for Clients to enroll in and there is <br />an incremental fee of $10 per initial determination. <br />■ Level 2 and Urgent Appeals are not included in the UM package fees. <br />■ The Level 2 and Urgent Appeal Service fee is not charged per appeal. It is charged for each initial <br />review. This allows Client to better estimate their appeal costs since it is based on the number of <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF EXPRESS SCRIPTS AND RXBENEFITS <br />Adniinistrative Services <br />Transaction Fees Payable for Administrative Services (per <br />Fees <br />$0.65 per Prescription Drug Claim made <br />Article IV.B of the Agreement) <br />by Members payable on a bi-monthlybasis <br />Transaction Fees Payable for Administrator's Clinical <br />Advantage Program <br />individual prices listed in table below <br />$1.45 i2er claim <br />Manufacturer op.I)rograms <br />Fees <br />Not Elected <br />• Out of Pocket Protection Accumulation <br />• Out of Pocket Protection + Variable Copay <br />Not Elected <br />Assistance Program <br />• SaveOnSP <br />Not Elected <br />• Out of Pocket Protection + SaveOnSP <br />$0.40 per claim (Elected) <br />Reviews and Appeals <br />• Low Clinical Value Exclusions CV <br />$0.30 per claim (Elected) <br />• High Dollar Claim Review R <br />$0.75 per claim (Elected) <br />Initial Determinations (i.e. coverage reviews) and Level <br />Included in the existing utilization <br />One Non -Urgent Appeals for the Coverage Authorization <br />management PMPM charge <br />Program, consisting of: <br />OR <br />Prior Authorization <br />Step Therapy <br />Included in the existing PA charge of $55 <br />Drug Quantity Management <br />per initial determination* <br />OR <br />No Charge if Client elects HDCR <br />Initial Determinations and Level One Non -Urgent Appeals <br />$55 per initial determination <br />for benefit reviews. Examples: copay review, plan <br />OR <br />excluded drug coverage review, administrative plan design <br />review. <br />No Charge if Client elects HDCR <br />Final and Binding Appeals — Level Two Appeals and/or <br />$10.00 per review* <br />Urgent Appeals for UM, formulary, and benefit reviews. <br />OR <br />No Charge if Client elects HDCR <br />External Reviews by Independent Review Organizations - for <br />$800 per review <br />non -grandfathered plans <br />OR <br />No Charile if Client elects HDCR <br />Third Party Integration Fees <br />Charges passed through from provider or <br />mutually agreed upon by Parties <br />The following terms and conditions apply only if client does not elect HDCR: <br />■ Initial determination — this is the first review of drug coverage based on the plan's conditions of <br />coverage. Initial determinations are also referred to as initial reviews, coverage reviews, prior <br />authorization reviews, UM reviews, or benefit reviews. <br />■ The Level 2 and Urgent Appeal Service is an optional service for Clients to enroll in and there is <br />an incremental fee of $10 per initial determination. <br />■ Level 2 and Urgent Appeals are not included in the UM package fees. <br />■ The Level 2 and Urgent Appeal Service fee is not charged per appeal. It is charged for each initial <br />review. This allows Client to better estimate their appeal costs since it is based on the number of <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF EXPRESS SCRIPTS AND RXBENEFITS <br />