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Implementation Package and Member Communications <br />New Member packets (includes two standard resin ID <br />Implementation support <br />cards) <br />Article IV.B of the Agreement) <br />Member replacement cards printed via web (For hard- <br />Member -submitted paper claims processing fee <br />copy card replacement, charges are passed through from <br />Medicaid subrogation claims fee <br />the PBM <br />Advanced Utilization Management (AUM Bundle) <br />Clinical <br />Concurrent Drug Utilization Review (DUR) <br />Call4Generics <br />Retrospective Drug Utilization Review (RDUR) <br />$0.10 PMPM per combined accumulator up to <br />Prior Authorization — Administrative <br />maximum of $0.20 PMPM for existing connection <br />a. Non -clinical Prior Authorization <br />with medical carrier or TPA. <br />b. Lost/stolen overrides <br />c. Vacation supplies <br />Fees to establish connection with new medical carrier <br />PBM Services <br />Fees <br />Transaction Fees Payable for Administrative Services (per <br />$0.65 per Prescription Drug Claim made by Members <br />Article IV.B of the Agreement) <br />payable on a bi-monthly basis <br />Member -submitted paper claims processing fee <br />$2.50/claim <br />Medicaid subrogation claims fee <br />$2.50/claim <br />Advanced Utilization Management (AUM Bundle) <br />$0.51 / PMPM <br />Combined Benefit Management <br />Services to manage combined medical -pharmacy benefits <br />$0.10 PMPM per combined accumulator up to <br />that are not a consumer -directed health (CDH) plan. <br />maximum of $0.20 PMPM for existing connection <br />Services include ongoing management of the data <br />with medical carrier or TPA. <br />exchange platform with the medical vendor/TPA, <br />production monitoring and quality control, and designated <br />Fees to establish connection with new medical carrier <br />operations team. Combined benefit types may include <br />or TPA are quoted upon request. <br />deductible, out of pocket, spending account, and lifetime <br />maximum. <br />Network Pharmacy Services <br />Network Pharmacy Audit Program <br />20% of audit recoveries <br />Reviews and Appeals Management <br />Initial Determinations (i.e. coverage reviews) and Level <br />Included in the existing utilization management <br />One Appeals for the Coverage Authorization Program, <br />PMPM charge <br />consisting of: <br />OR <br />Prior Authorization <br />Included in the existing PA charge of $55 per review <br />Step Therapy <br />Drug Quantity Management <br />Initial Determinations and Level One Appeals for the <br />$55 per review <br />Benefit Review Program, consisting of reviews known as: <br />Plan Design Related Requests <br />Plan Exclusion Reviews (clinical or administrative <br />reviews of non -covered drugs) <br />Copay Reviews <br />Plan Limit Reviews (e.g. age, gender, days' supply <br />limits) <br />Plan Rule/Administrative Reviews/Non-clinical <br />Reviews <br />Clinical Benefit Reviews <br />Direct Claim Reject Reviews <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />21 81 <br />