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DocuSign Envelope ID: 5332467E-CBEF-4C5D-8BOE-61 E380BDAl 1 B <br />DocuSign Envelope ID: 151 EGOGF-855C-414F-9455-72004347A310 <br />(112023 Version) <br />• Indian River County Board of County <br />No Charge (Elected) <br />Commissioners Clinical -All Plans -Remove <br />MCAP SaveOnSP fee <br />• Low Clinical Value Exclusions (LCV) <br />Elected <br />Indian River County Board of County <br />$0.30 per claim <br />Commissioners Clinical -All Plans - <br />Remove MCAP SaveOnSP fee <br />• High Dollar Claim Review (HDCR) <br />Elected <br />c Indian River County Board of County <br />$0,95 per claim <br />Commissioners Clinical -All Plans - <br />Remove MCAP SaveOnSP fee <br />Initial Determinations (i.e. coverage reviews) and Level <br />Included in the existiniz utilization <br />One Non -Urgent Appeals under the UM program. <br />management PMPM charge <br />Examples: Prior Authorization. Step Therapy, Drug <br />OR <br />Quantity Management <br />Included in the existing PA charge of $55 per <br />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 />No Charge if Client elects HDCR <br />review. <br />Final Internal Appeals Level Two Appeals and/or Urgent <br />S 10 per review* <br />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 />Miscellaneous <br />No Ch -g- 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 detemlination. <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 />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 ofclinical <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 I or Level 2. Urgent appeal decisions are final and <br />binding. If a Level I Appeal is processed as urgent. there is no Level 2 appeal. <br />NOT FOR DISTRIBUTION. TIIE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL„ PROPRIE"I'ARN' <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />