Laserfiche WebLink
DocuSign Envelope ID: 5332467E-CBEF-4C5D-8BOE-61 E380BDAl 1 B <br />DocuSign Envelope ID: 151 ECOCF-B55C-414F-9455-72004347A310 <br />(1/2023 Version) <br />maintained and updated by ESI from time to time. If ESI elects to bill Client's medical plan for <br />ASES, Administrator will work with ESI to coordinate the invoicing and payment of ASES through <br />Client's medical plan. If Client's medical plan will not cover the cost of ASES billed through ESI <br />or ESI Specialty Pharmacy, Client shall be responsible for the costs of all ASES. If a Specialty <br />Product dispensed or ASES provided by ESI Specialty Pharmacy is billed to Administrator or a <br />Client directly by ESI Specialty Pharmacy instead of being processed through ESI, Client will timely <br />pay Administrator, and Administrator will timely pay ESI Specialty Pharmacy for such claim <br />pursuant to the rates below. ESI Specialty Pharmacy shall have 360 days from the date of service <br />to submit such electronic or paper claim. <br />Therapeutic Cla ss <br />Am <br />Immune Deficiency <br />MMENNOC11 Brand Name <br />All Immune Deficiency Drugs requiring <br />Nursing & Per Diem <br />$60.00 / Infusion <br />Per Diem <br />Enzyme Deficiency <br />All Enzyme Deficiency Drugs required <br />$60.00 / Infusion <br />Per Diem <br />Miscellaneous Specialty <br />Duopa <br />$65.00 / Day <br />Conditions <br />Miscellaneous Specialty <br />Soliris <br />$60.00 Infusion <br />Conditions <br />PAH <br />Flolan, Veletri, Epoprostenol Sodium <br />$65.00 / Day <br />(generic-Flolan/Veletri), and Remodulin <br />PAH <br />Ventavis <br />$65.00 / Day <br />PAH <br />Tyvaso <br />$30.00 / Day <br />Inflammatory Conditions <br />Remicade <br />560.00 / Infusion <br />Alpha I Deficiency <br />All Alpha I Deficiency Drugs requiring <br />$55.00/Infusion <br />Per Diem <br />Nursing Rates <br />All drugs / therapies requiring nursing <br />$150.00 per initial visit up to two <br />(2) hours/$75.00 per additional <br />hour or a fraction thereof <br />(g) Specialty Products will be excluded from the non -specialty price guarantees set forth in the <br />Agreement. In no event will the ESI Mail Pharmacy or Participating Pharmacy pricing terms <br />specified in the Agreement, including, but not limited to, the annual average ingredient cost discount <br />guarantees, apply to Specialty Products. <br />3.3 Vaccine Claims (NO VACCINE CLAIMS WILL BE INCLUDED IN ANY PRICING OR <br />REBATE GUARANTEE SET FORTH IN THE AGREEMENT). <br />(a) General terms applicable to Vaccine Claims <br />"Vaccine Claim" means a claim for a Covered Drug which is a vaccine. <br />"Vaccine Vendor Transaction Fee" means the data interchange fee that ESI is charged by <br />its third party vendor to convert Vaccine Claims submitted electronically by physicians to <br />NCPDP 5.1 format in order for PBM to process the claim. <br />Vaccine Claims shall adjudicate at the lower of U&C or the amounts shown in the table <br />below. In the case of Vaccine Claims, the U&C shall be the retail price charged by a <br />Participating Pharmacy for the particular vaccine, including administration and dispensing <br />15 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />