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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />RYAN L. BUTLER, CLERK <br />Comprehensive Consumer Driven Health (CDtf) Solution <br />Technical <br />$0.48 PMPM <br />Bi-directional data exchange; dedicated operations; 24-hour <br />a day, seven -days a week monitoring and quality control; <br />performance reporting; and analytics <br />*these charges would be in addition to any <br />pricing adjustments if greater than ten percent <br />Decision Support <br />of Client's total utilization for all Plans is <br />Dedicated CDH member services, Prescription Benefit <br />attributable to a CDHC. These services and fee <br />Review Statements, Retail Pricing Transparency <br />are required for all CDH enrollees. <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 />$0.25 PMPM (If Elected) <br />Medicare Part 1 Retiree 1 1 <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 $7,500 <br />i Notice of Creditable Coverage <br />$1.35/letter + postage <br />RDS standard service (ESI sends reports to Client) <br />$0.62 PMPM for Medicare -qualified Members <br />with a minimum annual fee of $5,000 <br />A. Notice of Creditable Coverage <br />$1.35/letter + postage <br />Communication with physicians and/or members (e.g., <br />$1.35/letter + postage <br />program descriptions, notifications, formulary compliance, <br />non -Medicare EOBs etc. <br />Medicare EOB <br />$1.75/letter + postage <br />Custom non-standard materials Priced u on re nest <br />Electronic Pharmacy Benefit Eligibility Verification <br />Eligibility confirmation of pharmacy benefit coverage shared with prescribers and other healthcare <br />professionals through their Electronic Medical Records (EMR) 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, D3 -D8, and Narrative 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 su rt <br />PHM Services No Additional <br />Customer service for Members <br />Electronic claims processing <br />Electronic/on-line eligibility submission <br />Plan setup <br />Standard coordination of benefits (COB) <br />Software training for access to on-line <br />reject for primary carrier <br />system(s) <br />FSA eligibility feeds <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />