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Docusign Envelope ID: 4C195600-904A-41DA-A041-3005C422FD42 Docusign Envelope ID: 7CEFA800-59DE-49DA-8C58-D8DB41083547 (1/2024 Version) 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") ensure FDA -approved guidelines with respect to indications are being met. Utilizing the PBM or customized criteria, Administrator has carved out the QL/ST 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. This component requires that Client elect a standard Utilization Management Programs promoted by Administrator. NOTE: Client must have I1DCR component in place to elect UM. The following may apply: 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; or If denied, an appeal process is available. 2.3 Protect Proeram Guarantee • General: The Administrator clinical programs elected by Client shall be collectively referred to as the "Protect Solutions" for purposes of this Exhibit A. The fees associated with the Protect Solutions which are invoiced to the client shall be referred to herein as the "Protect Fees". • Protect ROI Guarantee: Administrator guarantees that Client will generate savings from the Protect Solutions ("Protect Savings') that are equal to or greater than the Protect Fees paid by Client during the given Contract Year (the "Protect ROI Guarantee'). To the extent that the Protect Fees exceed the Protect Savings in a given Contract Year, Administrator will pay Client an amount equal to the difference between the Protect Fees and the Protect Savings (the "Protect Guarantee Payment"). o For Clients with one thousand (1,000) Members or more, the Protect ROI Guarantee shall be 2:1. This means that following Client's Contract Year, if necessary, Administrator's Protect Guarantee Payment will consist of reimbursing Client for Protect Fees in an amount 8 NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS