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DocuSign Envelope ID: 5332467E-CBEF-4C5D-8BOE-61 E3806DAl 1 B DocuSign Envelope ID: 151 ECOCF-B55C-414F-9455-72004347A310 (1/2023 Version) If elected, Administrator's High Dollar Claim Review, Prior Authorization and Appeals program ("HDCR"), will provide Client with umbrella protection against high-cost Prescription Drug Claims for approved formulary drugs. Prescription Drug Claims over the threshold dollar amount are flagged prior to payment and reviewed for clinical appropriateness. This additional level of clinical oversight protects against unnecessary spending, saving clients money and providing improved visibility into claim reviews, decision processes, and cost savings. If HDCR is elected, Administrator's Complex Clinical Intervention ("CCI") program is included. CCI addresses complex case management issues for Plan Participants on a trajectory to generate more than $250,000.00 in annual pharmacy plan spend. Clinical pharmacists reach out to Prescribers to request and review medical documentation and tackle issues such as redundant therapies, dosing errors, potential drug -on -drug interactions, and medication misuse. o The following may apply to HDCR: • Administrator manages the clinical review process for high dollar claims, providing oversight of the process. Administrator communicates trends and savings results to clients through detailed reporting and analytics. ■ Review turnaround time is dependent on prescriber activity and whether additional information is required. If additional information is required, the reviewer will attempt to contact physician at least once daily for three days; direct contact with the prescriber will discontinue after the third day. The majority of reviews are completed with a disposition within 24 to 72 hours. • Following a clinical review, one of four actions will occur: (i) the medication is approved, (ii) the medication claim is denied, (iii) the prescriber may decide to withdraw and prescribe a different medication, or (iv) the reviewer can dismiss the claim due to lack of communication from the prescriber; ■ If denied, the appeal process is available. o If HDCR is elected, the Administrator will also manage all other Prior Authorizations and Appeals. • Following a clinical review, one of four actions will occur the medication is approved, the medication claim is denied, the doctor may decide to withdraw and prescribe a different medication, or the reviewer can dismiss the claim due to lack of communication from the prescriber; ■ If denied, the appeal process is available. o The appeal process: ■ If an initial review is denied, the Member may appeal the decision to have a different pharmacist reviewer evaluate the prior authorization. • If the denial is upheld upon first appeal, a second appeal may be made, which is completed in consultation with a peer physician reviewer from an Independent Review Organization. ■ If the denial is again upheld upon second appeal, a final appeal for a Federal External Review completed by an Independent Review Organization may be made. ■ If the denial is upheld by the final review, the appeal process has been exhausted and the decision is final and binding. Foundational Utilization Management ("UM"). UM is a bundling of evidence -based clinical programs commonly used to provide appropriate clinical oversight of prescription drug claims. UM ensures the correct clinical evaluation processes are in place. Appropriate quantity limit ("QL") promotes FDA - approved dispensing guidelines by ensuring appropriate quantities are dispensed. Step Therapy ("ST") ensures the most clinically appropriate item is used first as part of adhering to accepted guidelines. When faced with two similar agents, the lowest cost option is promoted first. Prior Authorizations ("PA'J ensure FDA -approved guidelines with respect to indications are being met. Utilizing the PBM or customized criteria, Administrator has carved out the QUST exception review process as well as all specialty and non -specialty PA reviews to be independently reviewed and documented utilizing a documentation system that allows for ease of auditing through increased visibility of clinical decisions. 8 NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS