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DocuSign Envelope ID:E8C538EF-9595-4E36-A4C9-2CA66C7BE34A
<br /> 2.2 Claims Processing: During the term of this Agreement, Envision shall accept, process,
<br /> and adjudicate Claims for Covered Drugs (i) submitted electronically by Participating
<br /> Pharmacies; (ii) submitted by Plan Sponsor's owned pharmacies or Plan Sponsor's contracted
<br /> pharmacies, if any, (not including 340B Claims, unless such claims are included under a separate
<br /> 340B Agreement); (iii) submitted by Covered Individuals as Direct Member Reimbursements
<br /> (DMRs, as defined below); or (iv) received from third parties, such as Medicaid, for
<br /> reimbursement by Plan Sponsor. Claims shall be checked for eligibility, benefit design, Cost
<br /> Share requirements, and exclusions to determine which Claims are successfully processed,
<br /> pended for prior authorization, or rejected for ineligibility or other factors in accordance with
<br /> Plan Sponsor's specifications as set forth in Plan Sponsor's Benefit Specification Form
<br /> (incorporated herein by this reference).
<br /> For Claims that must be processed manually or require special handling, including, without
<br /> limitation, (i) DMRs, (ii) Claims received from third parties, such as Medicaid, for
<br /> reimbursement by Plan Sponsor for ineligible payments, or (iii) paper Claims, Plan Sponsor will
<br /> be charged a Manual Claims Processing fee as set forth in Exhibit 1. After termination of this
<br /> Agreement, Envision shall process Claims received for dates of service on or before the effective
<br /> date of teunination for a period of ninety (90) days ("Run-Out Period"), subject to the following.
<br /> Plan Sponsor shall deposit and maintain, with Envision, an amount equal to the last Claims
<br /> invoice prior to termination. At the end of the Run-Out Period, the balance of the deposit shall
<br /> be promptly refunded to Plan Sponsor and, thereafter, any Claims received by Envision shall be
<br /> rejected.
<br /> 2.2.1 Direct Member Reimbursement (DMR): Envision shall provide, via its website, a
<br /> form for use by Covered Individuals to obtain reimbursement for amounts paid out-of-pocket
<br /> (other than Cost Share) for Covered Drugs (e.g. Covered Drugs dispensed at a non-Participating
<br /> Pharmacy) ("DMR Form"). Envision shall accept and process DMR Claims within ten (10)
<br /> business days of receipt of the DMR form, invoice Plan Sponsor for the Claim, and reimburse
<br /> the Covered Individual upon receipt of funds from Plan Sponsor.
<br /> 2.2.2 Claims from Non-Participating Pharmacies: Unless otherwise directed by Plan
<br /> Sponsor, Envision shall accept and process Claims received from non-participating government
<br /> owned or operated pharmacies (e.g. Veterans Administration).
<br /> 2.2.3 Claims Adjudication System Edits: Plan Sponsor's Benefit Plan may contain
<br /> additional rules which determine the way in which Claims are to be adjudicated. These rules
<br /> may include coverage limitations or exclusions, application of clinical intervention (e.g. step
<br /> therapy, drug therapy management), application of dispensed as written (DAW) codes (e.g. to
<br /> determine what portion of a Claim is payable by Plan Sponsor and what portion is payable by
<br /> Members), and administrative overrides to authorize the dispensing of Covered Drugs in certain
<br /> circumstances (e.g. requests for lost or stolen drugs, vacation supplies, certain package sizes,
<br /> dosage changes, invalid days' supply). For this purpose, Envision shall program edits into the
<br /> Claims Adjudication System which are applied to Claims during the adjudication process as
<br /> specified in the Benefit Specification Form. The Claims Adjudication System will provide the
<br /> dispensing pharmacy with the appropriate messaging to advise the pharmacy of the applicable
<br /> limitation, program, rule, or override.
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