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DocuSign Fnvelope ID: 5B185859-5943-4C41-90BF-OCE5E90FDADD <br />(01/2021 Version) <br />Part D subsidy enhanced service (ESI sends reports to CMS <br />$1.12 PMPM for Medicare -qualified <br />on behalf of Client) <br />Members with a minimum annual fee of <br />(i) Notice of Creditable Coverage <br />$7,500 <br />$1.35/letter+ postage <br />Part D Subsidy standard service (ESI sends reports to <br />$0.62 PMPM for Medicare -qualified <br />Client) <br />Members with a minimum annual fee of <br />$5,000 <br />A. Notice of Creditable Coverage <br />$1.35/letter + postage <br />Communication with physicians and/or members (e.g., <br />$1.75/letter + postage <br />program descriptions, notifications, formulary compliance, <br />non -Medicare EOBs etc. <br />Medicare EOB <br />$1.75/letter + postage <br />Custom non-standard materials <br />I Priced u on Request <br />Electronic Pharmac.N Benefit Eligibility Verification <br />Eligibility confirmation of pharmacy benefit coverage shared <br />with prescribers and other healthcare <br />professionals through their Electronic Medical Records (EMR) <br />or other digital channels. Pass-through <br />-charge to Sp2nsor at ESI's j2refeffed rate with data switch such <br />as Surescri ts. <br />Miscellaneous <br />Coordination of Benefits <br />$0.01 PMPM, If Elected <br />- Custom reimbursement formula <br />- Setup and ongoing maintenance <br />- Product support <br />Formulary Services Fee <br />$10,000 Implementation Fee + $0.05 <br />- High Performance Formulary <br />PMPM If Elected <br />Medicare Part B Solution <br />- Integrated Retail & Mail Program <br />- $0.42 PMPM <br />- Retail Only Program <br />- $0.20 PMPM <br />- Program IntroductoLetter <br />- $1.35/letter+ postage <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF EXPRESS SCRIPTS AND RXBENEFITS <br />