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Docusign Envelope ID: 4C 1 95600-904A-41 DA-A041-3005C422FD42 <br />DocuSign Envelope ID: 7CEFA800-59DE-49DA-8C5B-D8DB41083547 <br />(1/2024 Version) <br />Final Internal Appeals — Level Two Appeals and/or Urgent <br />$10.00 per review* <br />Appeals for UM, formulary, and benefit reviews. <br />OR <br />Member -submitted paper claims processing fee <br />No Charge if Client elects HDCRI <br />External Reviews by Independent Review Organizations - for <br />$800 per review <br />non -grandfathered plans <br />OR <br />ACA Statin "Trend Management" Program <br />No Charge if Client elects HDCR' <br />Miscellaneus <br />'ntegration Fees <br />7771 <br />Charges passed through from provider or <br />Services to manage combined medical -pharmacy benefits <br />mutually affccd upon by Parties <br />I Reviews not managed by Administrator under HDCR may incur an additional charge. <br />The following terms and conditions apply only if client does not elect HDCR or for reviews not conducted <br />by Administrator under 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 determination. <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 of clinical <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 1 or Level 2. Urgent appeal decisions are final and <br />binding. If a Level 1 Appeal is processed as urgent, there is no Level 2 appeal. <br />PBM Sei-vices <br />Advanced Utilization Management (AUM Bundle <br />Fees <br />$0.46 / PMPM or Passed through from PBM <br />Member -submitted paper claims processing fee <br />$3.00 per claim <br />Commercial Medicaid or Medicare subrogation claims fee <br />53.00 per claim <br />Advanced Opioid Management Program <br />$0.32 / PMPM If Elected <br />ACA Statin "Trend Management" Program <br />I S0.03 / PMPM If Elected <br />Combined Benefit Management <br />Services to manage combined medical -pharmacy benefits <br />50.10 PMPM per combined accumulator up to <br />that are not a consumer -directed health (CDH) plan. <br />maximum of 50.20 PMPM for existing <br />Services include ongoing management of the data exchange <br />connection with medical carrier or TPA. <br />platform with the medical vendor/TPA, production <br />monitoring and quality control, and designated operations <br />Fees to establish connection with new medical <br />team. Combined benefit types may include deductible, out <br />carrier or TPA are quoted upon request. <br />of pocket, spending account, and lifetime maximum. <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />