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DocuSign Envelope ID:E8C538EF-9595-4E36-A4C9-2CA66C7BE34A <br /> 13. Redeterminations (Internal Appeals) $125 per request <br /> 14. External Appeals including services of an 100%pass-through of costs incurred <br /> Independent Review Organization(IRO) (ranging between$250 to $350 per appeal, <br /> average cost is approximately$300 per <br /> appeal) <br /> 15. e-Prescribing $0.15 per transaction, minimum of$250.00 <br /> per month <br /> 16. Claim Adjustment Checks (charged to Plan <br /> Sponsor for reimbursements made to Covered <br /> Individuals for Claim adjustments requested by <br /> Plan Sponsor.) $8.50 per check <br /> 17. Explanation of Benefits (EOB)production and <br /> distribution $1.00 per EOB plus postage <br /> 18. Manual Claims Processing(including DMRs) $1.50 per Claim processed <br /> 19. Medicaid Subrogation Claim Adjudication $3.50 per Claim <br /> 20. Drug Therapy Care Gap Management $0.55 per Member,per month <br /> 21. Medication Adherence and Persistency(up to <br /> three disease states) $0.55 per Member,per month <br /> 22. Outgoing Data Transfer Files (Claims History, <br /> Prior Authorization Files, Open Refill Files (Mail <br /> and Specialty), Accumulator Files (deductible, <br /> out-of-pocket, etc.), and/or related participant data $5,000 for any or all of the identified <br /> files (i.e. patient addresses, etc.) reports <br /> Drug Pricing and Dispensing Fees(A) <br /> Supply/Source BRAND GENERIC <br /> Drug Price(B)(C) Dispensing Drug Price(B)(c) Dispensing <br /> For Contract Year 1 ' (Annual Average Fee(C) (Annual Average Fee(c) <br /> (based on 3 year Effective Rate (Annual Effective Rate (Annual <br /> Agreement) Guarantee) Average Guarantee) Average <br /> Guarantee) Guarantee) <br /> j Retail Pharmacy (30 AWP minus 16.10% $1.15 AWP minus $1.15 <br /> Days' Supply) 80.00% <br /> Retail Pharmacy (84 <br /> Days' Supply or AWP minus 21.50% N/A AWP minus N/A <br /> greater) (non-Mail 81.00% <br /> Order)(D) <br /> Mail Order Pharmacy AWP minus 23.00% N/A AWP minus N/A <br /> (84 Days' Supply or 83.00% <br /> \Pass-through PBMSA(041917) ©Envision Pharmaceutical Services,LLC Page 23 of 41 <br />