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Docusign Envelope ID: 4C195600-904A-41DA-A041-3005C422FD42 <br />DocuSign Envelope ID: 7CEFA800-59DE-49DA-8C5B-D8DB41083547 <br />(1/2024 Version) <br />PBM Senices <br />Basic Network Pharmacy Audit <br />Fees <br />No Charge, 100% of recoveries passed back to <br />Client <br />Comprehensive Consumer Driven Health (CDII) Solution <br />Technical <br />50.48 PMPM <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 />of Client's total utilization for all Plans is <br />Decision Support <br />attributable to a CDHC. These services and <br />Dedicated CDH member services, Prescription Benefit <br />fees are required for all CDH enrollees. <br />Review Statements, Retail Pricing Transparency <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 />50.25 PMPM (If Elected) <br />Medicare Part 1 Drug Subsidy1 <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 S7,500 <br />i Notice of Creditable Coverage <br />S 1.35/letter + postage <br />RDS standard service (ESI sends reports to Client) <br />50.62 PMPM for Medicare -qualified Members <br />with a minimum annual fee of S5,000 <br />A. Notice of Creditable Coverage <br />51.35/letter + postage <br />Communication with physicians and/or members (e.g., <br />S 1.75/letter + postage <br />program descriptions, notifications, formulary compliance, <br />non -Medicare EOBs, etc. <br />Medicare EOB <br />1 S1.75/letter+ postage <br />Custom non-standard materials <br />I Priced upon request <br />Electronic Pharmacy Benefit Eligibility Verification <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 />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />