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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 />No Additional Fee <br />Customer service for Members Electronic claims processing <br />Electronic/on-line eligibility submission <br />Plan setup <br />Standard coordination of benefits (COB) <br />Software training for access to on-line <br />(reject for primary carrier) <br />system(s) <br />FSA eligibility feeds <br />A. Network Pharmacy Services <br />Pharmacy help desk <br />Pharmacy reimbursement <br />Pharmacy network management <br />Network development (upon request) <br />B. Home Delivery Services <br />Benefit education <br />Prescription delivery – standard <br />Web -based client reporting <br />Annual Strategic Account Plan report <br />.Ad-hoc desktop parametric reports <br />Billing reports <br />Claims detail extract file electronic (NCPDP format) <br />Inquiry access to claims processing system <br />Load 12 months claims history for clinical reports and <br />re orcin <br />Website Services <br />Express- Scripts. com for Members — access to benefit, <br />Mobile App for Members — Includes My Rx <br />drug, health and wellness information; prescription <br />Choices, My Medicine Cabinet, Pharmacy <br />ordering capability: and customer service <br />Care Alerts, Refills and Renewals, and virtual <br />12rescril2tion ID card. <br />44 <br />,,Implementation Package and Nlember ( onimunications <br />• New Member packets (includes two standard resin ID <br />cards or virtual cards, depending on PBM's procedures) <br />• Member replacement cards printed via web (for hard- <br />copy cards, charges are passed through from the PBM <br />• Member -requested replacement packets or Client <br />S1.50 + postage per packet or card <br />requested re -carding <br />Concurrent Drug Utilization Review (DUR) No Charge <br />Overrides <br />a. Client -requested overrides <br />b. Lost/stolen overrides <br />c. Vacation supplies <br />2.2 Administrator Clinical Programs <br />If elected, the Lois, Clinical Value ("LCV') exclusion option prevents unnecessary spending by <br />removing LCV medications from the formulary without impact to client rebates while providing equal <br />or more effective medicines at a lower cost. LCV medications are drugs that treat common conditions <br />that do not provide any additional or superior therapeutic value when compared to currently existing <br />therapies already in the marketplace. These medications are excluded in addition to any products that <br />would normally be excluded by the PBM Formulary. This exclusion occurs without affecting Rebate <br />minimum guarantees or contracted discount rates. Administrator reserves the right to amend, from time <br />to time, the list of low clinical value medications. The list of low clinical value medications may be <br />updated quarterly. Client may request a current list of LCV medications. <br />7 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, 11ROPRIETAIII' <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />