Healthcare Management Administrators (HMA) 2/20/2025

Proving What’s Possible in Healthcare This document contains important terms and conditions which are incorporated by reference into and becomes part of the terms of your contract with us. ©2024, Healthcare Management Administrators, Inc. 30 Pharmacy Benefits Additional fees, pricing, terms and Conditions as follows are for Sponsors on our contract and are effective January 2025 –December 2025. 1. For the Generic Effective Rate Guarantees, both Single Source Generics and Multisource Generics are included in the calculation. “Single Source Generic” means a drug that is manufactured by and available from only one generic pharmaceutical manufacturer. “Multisource Generic” means a drug is manufactured by and available from more than one generic pharmaceutical manufacturer. Claims for compound drugs, Specialty Drugs (except in connection with a Specialty Drug guarantee, as applicable), over-the- counter drugs, Claims with ancillary charges (but not taxes), Member-submitted Claims received after reconciliation is completed, Subrogation Claims, out-of-network Claims, Claims for Specialty Drugs funded through the MRx Select Savings Program, Claims for products used in the detection, prevention, or treatment of COVID-19, Claims for products subject to an Emergency Use Authorization (EUA), and Claims from in-house pharmacies (unless such pharmacy is in the MRx network) are excluded from the calculations. Value Max Claims are excluded from the calculation of Dispensing Fee Guarantees. Under the Retail Pharmacy guarantees, Claims from LTC Pharmacies, Home Infusion Pharmacies, and Indian/Tribal/Urban Pharmacies are excluded from the calculations, and there are no guarantees applicable to individual pharmacies. A Mail Order Pharmacy Claim for less than an 84 days’ supply will be included in the Retail Pharmacy guarantee calculations. For Sponsors with fewer than 750 members, Guarantees will be reconciled and applicable at our book of business level and will be measured and reconciled at the end of our book of business Contract Year and MagellanRx may offset any surplus on any Effective Rate, Dispensing Fee Guarantee, or Rebates against a shortfall in any other such guarantee. For Sponsors with 750 or more active Members, Guarantees will be reconciled and applicable at the Sponsor level and will be measured and reconciled at the end of each applicable Sponsor’s Contract Year and MagellanRx may offset any surplus on any Effective Rate or Dispensing Fee Guarantee within a dispensing channel (i.e., Retail Pharmacy, Mail Order Pharmacy, Specialty Drugs) against a shortfall in any other guarantee within the same dispensing channel. (continues on next page) Administrative Fees (Value Added) Service Description Fee Manual Eligibility $2.20 per Eligibility Record Electronic Prescribing $0.16 per positive eligibility transaction Retroactive Termination Letters Quoted Upon Request Member Packets (mailed directly to Member)$1.25 per Member address + Postage ID Cards $0.25 per card (Rx Only) Customized Materials (Member packets or other communications)Quoted Upon Request Member Mailings $1.25 per letter + Postage Direct Member Reimbursement (Member submitted manual/paper Claims)$1.50 per Claim + Postage and Core Administrative Fee MRx Standard Prior Authorization Program $40.00 per review Appeals $150.00 per review Independent Review Organization (IRO)Pass Through fees from IRO entity Processing Subrogation Claims $3.00 per Subrogation Claim Custom ad hoc reporting $195.00 per hour RDS Support Services Quoted Upon Request Custom FWA Program Quoted Upon Request Sponsor Requested audits of pharmacy On Site Audit: $1,500.00 per audit Desk Audit: $500.00 per audit Physician charges relating to UM activities Pass through of physician charges