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Proving What’s Possible in Healthcare <br />This document contains important terms and conditions which are incorporated by reference into and becomes <br />part of the terms of your contract with us. ©2024, Healthcare Management Administrators, Inc. <br />19 <br />Additional Fees <br />Description Price <br />Manual Eligibility Submission $1.00/ Manual Entry <br />Manual/Paper Claim Submissions $1.50/ Per Processed Claim <br />Client Specific Programing $150.00 per hour <br />RxDC Reporting Filing Fee $0.02 PMPY <br />Rx MRF Fees Fees to be established and will be passed through to client <br />Transparent Network Fees 1 $1.50 Per Claim <br />State Regulatory Impact Assessment2 $0.51 per retail claim only <br />Misc. Fees <br />Description Price <br />Prior Authorization $30.00 per Prior Authorization <br />State Regulation required denial oversight by Physician for <br />Prior Authorization Request (per request) <br />$45.00 Internal CVS Caremark Physician <br />$55.00 External Physician <br />External Review $500.00 per IRO external review requested <br />Specialty Guideline Management $30.00 per review (Open-Formulary) <br />$0.00 per review (Exclusive Specialty) <br />Formulary Exception $30.00 per request <br />Vaccine Program Management fee $0.05 per member per month <br />Vaccine Administration fee $20 per vaccine claim <br />Shipping of temperature sensitive medications $22 per non-specialty mail temperature sensitive <br />Appeals Fees <br />Description Price <br />1st Level Appeals $100.00 per review <br />2nd Level Appeals $500.00 per review <br />Urgent 1st Level Appeals with an IRO $600.00 per review <br />Retail Network Pharmacy 3rd Party Appeal Pass through fees per review <br />Pharmacy Benefits <br />Additional Fees as follows are for clients on our contract and <br />are effective January 2025 –December 2025.* <br />*Please Note: <br />•Other fees, terms and conditions apply –please see the CVS/Caremark Add’l Fees, Pricing, Terms & Condition section. <br />•Please see Participating Group Agreement and supplement documents for full Terms and Conditions. <br />•Standard implementation requires a minimum of 100 days prior written notice. PrudentRx requires a minimum of 130 days prior <br />written notice. <br />1 -States that require a Transparent Network will be billed $1.50 per claim in those states. Current states that require a <br />Transparent Network include: FL, TN, WV, OK, AR (subject to change) <br />2-Applies to claims in select states with relevant regulatory requirements. The current list of states includes AL, AR, AZ, CO, DE, <br />FL, GA, IA, LA, MD, MI, ND, NM, OK, SD, MS, NJ, TN, VA, TX, WA, WV, WY and is subject to change.