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DocuSign Envelope ID: 5332467E-CBEF-4C5D-8B0E-61E380BDAl1B <br />DocuSign Envelope ID: 151ECOCF-B55C-414F-9455-72004347A310 <br />(1/2023 Version) <br />NOTFOR DISTRIBUTION. THE INF'ORMA'TION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />Fees <br />$0.48 PMPM <br />PBNI Services <br />Com I) relienshe Consumer Driven I lea It It (('1)11) Solution <br />Technical <br />Bi-directional data exchange; dedicated operations; 24-hour <br />a day, seven -days a week monitoring and quality control; <br />*these charges would be in addition to any <br />performance reporting; and analytics <br />pricing adjustments if greater than ten percent <br />Decision Support <br />of Client's total utilization for all Plans is <br />Dedicated CDH member services, Prescription Benefit <br />attributable to a CDHC. These services and <br />Review Statements, Retail Pricing Transparency <br />fees are required for all CDH enrollees. <br />Member Adherence <br />ScreenRx <br />Preventive Medications <br />Member Education <br />Proactive, personalized member communications open <br />enrollment tools and member communications library, <br />robust online features, and preventive care proactive, <br />personalized member communications <br />ScreenRx for PPO Plans <br />$0.25 PMPM (If Elected) <br />Medicare Ilart 1) - Retiree Drug Stibsid� (RDS) <br />RDS enhanced service (ESI sends reports to CMS on behalf <br />$1.12 PMPM for Medicare -qualified Members <br />of Client) <br />with a minimum annual fee of $7,500 <br />i Notice of Creditable Coverage <br />$1.35/letter + postage <br />RDS standard service (ESI sends reports to Client) <br />$0.62 PMPM for Medicare -qualified Members <br />with a minimum annual fee of $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 + osta e <br />Custom non-standard materials <br />Priced upon reguest <br />Electronic Pharmacy Rencrit Eligibility %'crification <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 charge <br />to Client at PBM's preferred rate with data switch such as Surescripts. <br />Miscellaneous <br />RxDC Reporting (Submission of P2, 133-138, and Narrative <br />Charges passed through from PBM <br />Response file via HIOS, and any other files deemed <br />necessary) <br />Coordination of Benefits <br />$0.01 PMPM, If Elected <br />- Custom reimbursement formula <br />Setup and ongoing maintenance <br />- Product support <br />Medicare Part B Solution <br />- Integrated Retail & Mail Program <br />- $0.42 PMPM <br />- Retail Only Program <br />- $0.20 PMPM <br />- Program Introductory Letter <br />- $1.35/letter + postage <br />NOTFOR DISTRIBUTION. THE INF'ORMA'TION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />