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Docusign Envelope ID: 4C1 95600-904A-41 DA-A041-3005C422FD42 DocuSign Envelope ID: 7CEFA800-59DE-49DA-8C5B-D8DB41083547 (112024 Version) C. SERVICES: FORMULARY: PRICING GUARANTEES. 1. Base Administrative Services. The following services are the base administrative services made available to Client and its Members pursuant to the Agreement (including this Exhibit A (the "Base Administrative Services"), as applicable: • Administration of eligibility submitted via telecommunication or electronically • Eligibility maintenance • Client support system for on-line access to current eligibility • Administration of Client's Plan Design • In -network claims adjudication via on-line claims adjudication system • Designated Account Team • Client clinical and plan consulting, analysis and cost projections • Annual analysis of program utilization and impact of plan design and managed care interventions • Welcome Package and ID Cards (hard copy or digital) for new Members • Standard Member communications • Toll-free telephone access to customer service for the program for use by Members and Client's benefits personnel and representatives 2. Additional Administrative Services. Client will pay for additional administrative services (the "Additional Administrative Services") beyond those included in the Base Administrative Services that are requested by Client and provided or made available by Administrator under the program as follows: 2.1 Transaction Fees NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS Fees Administrative Services Transaction Fees Payable for Administrative Services (per $0.65 per Prescription Drug Claim made by Article IV.B of the Agreement) Members payable on a bi-monthly basis Transaction Fees Payable for Administrator's Protect Program $2.00 er claim Fees Manufacturer Copay Assistance Programs Out of Pocket Protection Accumulation Not Elected SaveOnSP Not Elected Out of Pocket Protection + SaveOnSP Reviews and Appeals No Charge Elected Initial Determinations (i.e. coverage reviews) and Level Included in the existing utilization One Non -Urgent Appeals under the UM program. management PMPM charge Examples: Prior Authorization, Step Therapy, Drug OR Quantity Management Included in the existing PA charge of $55 per initial determination* OR No Charge if Client elects HDCRI Initial Determinations and Level One Non -Urgent Appeals $55 per initial determination for benefit reviews. Examples: copay review, plan excluded drug coverage review, administrative plan design review. NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS