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HMA Client Intent & TPA Exhibit A – City of Everett 020188 Page 7 of 8 <br />020188 City of Everett 2025.01 Client Intent Exhibit A_Single Year 5.14.2024 Add Renewal Fee Product <br />☐ $1.00 MDLIVE Medical (Urgent Care) Only PEPM <br /> <br />Please detail the group’s required cost share for any plans that apply: <br />☐ PPO plan member copay amount of $________ per virtual visit, deductible waived <br />☐ PPO plan member copay amount of $________ per virtual visit after deductible met <br />☐ HDHP plan member coinsurance amount of _________% <br /> <br />☐ $2.60 Virtual Behavioral Health Product Option A PEPM <br />(6 counseling + 6 coaching per enrolled employee/family unit, per incident, per year) <br /> <br />(By election Virtual Health Option, A or B, any exclusions within the SPD will be updated to align with <br />Virtual Behavioral Health product offerings) <br />☐ $3.75 <br /> <br />Virtual Behavioral Health Product Option B PEPM <br />(12 counseling + 12 coaching per enrolled employee/family unit, per incident, per year) <br /> <br />(By election Virtual Health Option, A or B, any exclusions within the SPD will be updated to align with <br />Virtual Behavioral Health product offerings) <br /> <br />*A $2.00 per card ID Card Fee applies when changes are made to the template, for example, deductible and out-of- <br />pocket or Pharmacy Benefit Manager changes. Incidental individual card replacement or reissue available upon <br />member request through our portal at no cost. <br />**HMA reserves the right to invoice costs plus 20% of printing and mailing charges for member materials. Printing <br />and mailing member materials and other collateral, including but not limited to SBCs, Member Guides, product <br />flyers, etc. <br />***HRIS vendor change requests within-3 years of initial set-up incur a charge of $5,000. <br /> <br />Pharmacy Benefit Administration <br />☐ I have read and accept the attached terms and conditions regarding PBM Fees & Services. <br />Stop Loss Services <br />☐ I have read and accept the attached terms and conditions regarding Excess Loss Services. <br />Renewal Products and Disclosures Acknowledgement <br />☐ I have read the attached Renewal Product Terms and Disclosures, and I accept the terms and <br />conditions contained within. <br /> <br />This Agreement incorporates by reference the terms and conditions set forth in the Renewal Product Terms & <br />Disclosures document, as if fully set forth herein. <br /> <br /> <br />Acceptance <br />IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their duly authorized <br />representatives on the respective dates set forth below, effective as of the day and year first above written. <br /> <br />Docusign Envelope ID: CC50B3B8-52FD-4DD0-8AA5-5843B00BE3B8