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A TRUE COPY CERTIFICATION ON LAST PAGE PYAN L. BUTLER, CLERK PBM or Administrator -developed 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 Program promoted by Administrator. If Client has elected UM and Administrator's Protect program, UM is managed by Administrator. If Client has elected UM but not Administrator's Protect program, UM may be managed by PBM. The following may apply to UM: ■ 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 or deny the claim due to lack of communication from the prescriber; or ■ If denied, an appeal process is available. 2.2 Protect Program 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"). 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 such that the ratio of Client's Protect Savings to Client's net Protect Fees is 2:1. Notwithstanding the foregoing, in no event will Administrator reimburse Client in an amount greater than the Protect Fees paid by Client during the applicable Contract Year. For purposes of calculating Member count, Administrator shall, on a monthly basis, calculate how many Members are active during the given month. At the end of the Contract Year, Administrator shall take the sum total of each month and divide it by the number of months in the Contract Year. If the average Member count over the course of the Contract Year is 1,000 Members or greater, the Protect ROI Guarantee shall be 2:1. At no point during the Contract Year can the monthly Member count fall below 900 Members; in the event that it does, the Protect ROI Guarantee for the Contract Year shall revert to 1:1 (as described in the immediately preceding paragraph). o Conditions: o Client's entire population must be enrolled in the Protect Solutions for Client to be eligible for the Protect ROI Guarantee. If any portion of Client's population is not enrolled in the Protect Solutions for the entire applicable Contract Year, the Protect ROI Guarantee will not be applicable to Client. Administrator reserves the right not to honor the Protect ROI Guarantee if Client makes overrides from the Protect Program Claims reviews/appeals. o Eligibility. To be eligible for the Protect ROI Guarantee, Administrator's LCV and HDCR programs (including PA, HTI, and CCI) must be elected and Administrator (or a vendor NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS