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DocuSign Envelope ID:E8C538EF-9595-4E36-A4C9-2CA66C7BE34A <br /> EXHIBIT 1 <br /> FEES AND FINANCIAL GUARANTEES <br /> Administrative Fee (Payable to Envision;not including fees payable to Plan Sponsor's TPAs, <br /> consultants, or brokers,if any)! <br /> For Contract Year 1: $1.89 per Claim <br /> For Contract Year 2: $1.97 per Claim <br /> For Contract Year 3: $2.04 per Claim <br /> Fees for Additional Services and Miscellaneous Expenses <br /> 1. Manually create or update the Eligibility File $1.00 per Covered Individual data entry <br /> 2. Custom Eligibility File layouts (accommodation <br /> or development) $1,000.00 per layout <br /> 3. Replacement by Envision of lost or stolen ID $1.00 per card plus cost of postage <br /> Cards (individual), <br /> $2.00 per card(family)plus $0.15 per ID <br /> Card packet and cost of postage <br /> 4. Member Communications Cost of production and postage <br /> 5. Standard Online Reporting User Access Standard Online Reporting includes access <br /> for 3 active Plan Sponsor users and 1 <br /> consultant user. A licensing fee of <br /> $1,200.00 would apply for each additional <br /> user. <br /> 6. Ad Hoc Computer or Report Programming(for a $150.00 per programming hour for ad hoc <br /> one-time, non-recurring report) report requests <br /> 7. Development of Ad Hoc Non-Standard Recurring <br /> report Quoted upon request <br /> 8. Incoming Data Transfer Files $250.00 per industry-standard file <br /> (non-industry standard file formats will be <br /> quoted upon request) <br /> 9. Benefit Integrity Enhanced Services (as set forth <br /> in the Benefit Integrity Enhanced Services To be quoted upon request, and based upon <br /> Addendum) service area <br /> 10. Submission of Medicare Part D subsidy $1.00 per Member,per month,minimum <br /> $2,000 per year <br /> 11. Customized Formulary $0.20 per Member,per month,minimum <br /> of$2,000 per month <br /> 12. Coverage Determinations (including Clinical Prior $35.00 per request <br /> Authorizations) <br /> \Pass-through PBMSA(041917) ©Envision Pharmaceutical Services,LLC Page 22 of 41 <br />