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A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK 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 Administrative Transaction Fees Payable for Administrative Services (per $0.65 per Prescription Drug Claim Article IV.B of the Agreement) Transaction Fees Payable for Administrator's Protect Program $2.25 ner claim Reviews and Appeals Management 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 HDCR' 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. Final Internal Appeals — Level Two Appeals and/or Urgent $10 per review Appeals for UM, formulary, and benefit reviews. OR No Charge if Client elects HDCR' External Reviews by Independent Review Organizations - for $800 per review non -grandfathered plans OR No Charge if Client elects HDCR' Miscellaneous Third Party Integration Fees Charges passed through from provider or mutually agreed upon by Parties NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS