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DocuSign Envelope ID: 5332467E-CBEF-4C5D-860E-61E380BDAl 1B DocuSign Envelope ID: 151ECOCF-B55C-414F-9455-72004347A310 (1/2023 Version) • PPO AWP -85.75% BRAND 0201 • PPO BRAND GENERIC • PPO AWP - 23.5% GENERIC • PPO • MAIL SERVICE PPO PHARMACY AWP - 85.75% BRAND • PPO $0.35 dispensingfee • PPO AWP - 25% GENERIC • PPO $0.00 dispensing fee • PPO AWP - 88.75% Prescription Drug Claims Excluded: Specialty Products (other than specialty guarantee), 340B Claims, Subrogation Claims, long term care pharmacy claims, Member Submitted Claims, compounds, OTC products (excluding insulin, diabetic strips, and test strips), vaccines, U&C, and Exclusive or Limited Distribution Products, claims with ancillary charges, products filled through in-house phannacies and COB claims. (b) Dispensing Fee. Administrator will guarantee an average aggregate annual per Prescription Drug Claim dispensing fee on Client utilization to be calculated as follows: [total dispensing fee of applicable Prescription Drug Claims for the annual period divided by total of applicable Prescription Drug Claims for the annual period] PARTICIPATING PHARMACY BRAND • PPO $0.35 dispensing fee GENERIC RETAIL MAINTENANCE • PPO NETWORK (84-90 $0.35 dispensing fee I. BRAND • PPO $0.35 dispensing fee GENERIC Iff,"MAIL PHARMACY BRAND • PPO $0.35 dispensingfee • PPO $0.00 dispensing fee GENERIC • PPO $0.00 dispensing fee Prescription Drug Claims Excluded: Specialty Products (other than specialty guarantee), 340B Claims, Subrogation Claims, long tern care phannacy claims, Member Submitted Claims, compounds, OTC products (excluding insulin, diabetic strips, and test strips), vaccines. U&C, and Exclusive or Limited Distribution Products, claims with ancillary charges, products filled through in-house phannacies and COB claims. IF) NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED IIlsREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RNBENEFITS