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Docusign Envelope ID: 4C1 95600-904A-41 DA-A041-3005C422FD42 <br />DocuSign Envelope ID: 7CEFA800-59DE-49DA-8C58-D8DB41083547 <br />(112024 Version) <br />PBM Services Fees <br />Medicare Part B Solution <br />Integrated Retail & Mail Program $0.42 PMPM <br />- Retail Only Program - $0.20 PMPM <br />- Program Introductory Letter - $1.35Aetter + 12ostage <br />PBM Services – No Additional <br />Customer service for Members Electronic claims processing <br />Electroniclon-line eligibility submission Plan setup <br />Standard coordination of benefits (COB) Software training for access to on-line <br />(reject for primary carrier 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 delicry – standard <br />Reporting <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 CPDP format <br />Inquiry access to claims processing system <br />Load 12 months claims history for clinical reports and <br />r ortin <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 />_prescril2tion ID card. <br />Implementation Package and Member Communications <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 />S 1.50 + postage per packet or card <br />requested re -carding <br />Concurrent Drug Utilization Review (DUR) <br />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 Low Clinical Value ("LCV') exclusion option prevents unnecessary <br />spending by removing LCV medications from the formulary without impact to client <br />rebates while providing equal or more effective medicines at a lower cost. LCV <br />medications are drugs that treat common conditions that do not provide any additional or <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />