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DocuSign Envelope ID:E8C538EF-9595-4E36-A4C9-2CA66C7BE34A <br /> Envision shall also program edits into the Claims Adjudication System which are applied to <br /> Claims during the adjudication process to identify the following drug utilization conditions: <br /> duplicate prescriptions; over-utilization/refill too soon; under-utilization; drug interactions; <br /> pediatric warnings; geriatric warnings; acute/maintenance dosing; therapeutic duplication; drug <br /> inferred health state; drugs exceeding maximum dose; and drugs below minimum daily dosage, <br /> as 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 drug utilization <br /> issues. <br /> 2.3 Clinical Services <br /> 2.3.1 Clinical Prior Authorizations (Initial Coverage Determinations): If Plan Sponsor <br /> has elected to receive Clinical Prior Authorization services from Envision, for those Covered <br /> Drugs and circumstances specified by Plan Sponsor in the Benefit Specification Form, Envision <br /> shall contact the prescriber and verify that the requested drug is appropriate for the diagnosis in <br /> the judgment of the prescriber. Plan Sponsor will be charged for Clinical Prior Authorizations as <br /> specified in Exhibit 1. If additional internal appeals (redetermination) and/or the services of an <br /> Independent Review Organization are to be provided under this Agreement, such services shall <br /> be included in a separate or attached coverage determination and appeals process addendum. <br /> 2.3.2 Drug Therapy Management (DTM) Programs: Envision offers clinical programs <br /> such as Drug Therapy Care Gap Management and Medication Adherence and Persistency. If <br /> clinical programs are to be provided under this Agreement, such services and any additional <br /> charges shall be set forth in a separate or attached clinical programs exhibit. <br /> 2.4 Pharmacy Network: Envision shall arrange for the dispensing of Covered Drugs to <br /> Covered Individuals pursuant to contracts with one or more networks of Participating <br /> Pharmacies (each referred to herein as a"Network"). The Network designated for Plan Sponsor <br /> to be used by Covered Individuals hereunder shall be specified in the Benefit Specification <br /> Form. Plan Sponsor acknowledges that the pharmacies participating in a Network may be <br /> changed from time to time by Envision, including the designated Mail Order Pharmacy and/or <br /> Specialty Pharmacy provider. Contact information for Participating Pharmacies is constantly <br /> updated to reflect any changes and is accessible via Envision's website. Plan Sponsor <br /> acknowledges that (i) orders exceeding a thirty day supply are not available at all Retail <br /> Pharmacies; (ii) Covered Drugs shall not be dispensed to Covered Individuals without a <br /> prescription order by a Prescriber; and (iii) the availability of drugs are subject to market <br /> conditions and that Envision cannot, and does not, assure the availability of any drug from any <br /> Participating Pharmacy. <br /> 2.4.1 Plan Sponsor Owned Pharmacies. If Plan Sponsor desires to include one or more <br /> of its owned or affiliated pharmacies in the network of pharmacies authorized to dispense <br /> Covered Drugs to Plan Sponsor's Covered Individuals, it shall indicate same on the Benefit <br /> Specification Form. If Plan Sponsor desires its pharmacy to be available to other Envision <br /> clients using one or more of Envision's Networks, such pharmacy shall enter into an Envision <br /> Participating Pharmacy Agreement (PPA). If the pharmacy will be for the use of Plan Sponsor's <br /> \Pass-through PBMSA(041917) ©Envision Pharmaceutical Services,LLC Page 6 of 41 <br />