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DocuSign Envelope ID: 5332467E-CBEF4C5D-8BOE-61 E380BDAI I B <br />DocuSign Envelope ID: 151 ECOCF-B55C-414F-9455-72004347A31 0 <br />(1/2023 Version) <br />fees, in a cash transaction on the date the vaccine is dispensed as reported to PBM by the <br />Participating Pharmacy. <br />4. The Vaccine Administration Fee for Vaccine Claims for Members enrolled in Client's <br />Medicaid programs, if any, will be capped at the maximum reimbursable amount under the <br />state Medicaid program in which the Member is enrolled. <br />5. All Vaccine Claims will be subject to any Transaction Fees set forth in the Agreement. <br />6. Vaccine Claims will be charged a program fee of $2.50 per Vaccine Claim (except for <br />Medicare Part D covered Vaccine Claims, if applicable). The Vaccine Program Fee will <br />be billed separately to Client as part of the administrative invoice according to the billing <br />frequency set forth in this Agreement. <br />(b) Commercial (Including Medicaid and Exchange, if applicable) <br />(c) Medicare Part D Covered Vaccine Claims: Medicare Part D Vaccine Claims shall adjudicate at the <br />lower of U&C or the amounts shown in the table below. <br />16 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />Participating Pharmacy <br />Member Submitted <br />Pharmacy <br />INFLUENZA <br />Pass -Through <br />OTHERParticipating <br />ALL <br />VACCINES <br />Pass -Through <br />(excluding foreign claims) <br />Vaccine <br />Administration <br />(capped(capped <br />at <br />at $20 per <br />Fee <br />vper <br />vaccine <br />vaccine cll aim) <br />vaccine claim and $40 <br />Submitted amount <br />per covid vaccine claim <br />Ingredient Cost <br />Participating Pharmacy <br />Participating Pharmacy <br />Ingredient Cost as set <br />Ingredient Cost as set <br />Submitted amount <br />forth in the Agreement <br />forth in the Agreement <br />Dispensing Fee <br />Participating Pharmacy <br />Participating Pharmacy <br />Dispensinge as set <br />Dispensing Fee as set <br />Submitted amount <br />forth in the�A,reernent <br />forth in the Agreement <br />Administrative <br />Administrative Fee per Prescription Drug Claim as <br />Administrative Fee per <br />Fee/Vaccine <br />set forth in the Agreement <br />Prescription Drug Claim <br />Claim <br />(plus manual claim <br />administrative fee) as set <br />forth in the Agreement <br />Vaccine Program <br />$2.50 per vaccine claim <br />N/A <br />Fee <br />(c) Medicare Part D Covered Vaccine Claims: Medicare Part D Vaccine Claims shall adjudicate at the <br />lower of U&C or the amounts shown in the table below. <br />16 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />