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<br />STANDARD HRA SERVICES <br /> <br />Description of Standard Service Fee Applied <br /> <br />Initial Set-Up Fee $250.00 <br /> <br />Annual renewal fee $250.00 <br /> <br />Monthly Account Fee: PEPM $4.50 <br /> <br />VISA Debit Card - (2) (multiple purse card) $0 <br /> <br />Debit Card Replacement (per set of 2) $5.00 <br /> <br />Electronic ACH Funds reimbursement $0 <br /> <br />Mobile App $0 <br /> <br />Text Message Notifications $0 <br /> <br />Debit Card Transaction <br />$0 <br /> <br />Electronic HRA Account Summary <br />$0 <br />Optional: Check Reimbursement and/or Pay-the-Provider <br />(Employer decision) - $0.50 per participant per month. Additional <br /> <br />$0.50 <br />fee applies to all HRA participants. Debit card payment available at <br />no additional charge. <br /> <br />Stop Check Service $25.00 <br />Optional: EOB Retrieval Feature: $250 annual set up & $0.50 per $250 Annual <br /> <br />employee per month. Billed on all account holders. $0.50 PEPM <br />Fee to correct erroneous data provided by Employer or Plan $150.00/hour+ <br /> <br />Administrator paper & postage <br /> <br />Prenote fee $1 per prenote <br />Standard communication materials provided electronically (pdf <br />version) (some materials will reflect actual plan provisions, but no <br /> <br />$0 <br />custom fonts, wording, logos, etc.; customization is available <br />see below for optional services and fees) <br />Optional: Rush Implementation (less than 30 days until start <br /> <br />N/A <br />date) $250.00 <br />Optional: Customized materials available at $150 per hour for <br /> <br />$150 per hour <br />creative and provided electronically (pdf version) <br />Optional: Printed materials can be provided at cost of print and <br /> <br />Custom <br />postage <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />MEDSURETY, LLC <br />18 <br />Administration Agreement (Non-ERISA) Exhibit <br />Business Associate Agreement <br /> <br />