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DocuSign Envelope ID: 5332467E-CBEF-4C5D-8BOE-61E38OBDA11B DocuSign Envelope ID: 151ECOCF-B55C-414F-9455-72004347A310 (12023 Version) Vendor FORMULARY:1 PARTICIPATING PHARMACIES 1-83 DAYS' SUPPLY Pass-through at ESI cost Transaction Fee $270.00 per Brand Drug claim PARTICIPATING 1111ARMACIES (84-90 DAYS' SUPPLY for Vendor Transaction • PPO N/A N/A Fee (currently $3.75, • PPO $710.00 per Brand Drug claim SPECIALTY PRODUCTS subject to char e D. REBATES Rebate Amounts. Subject to: (i) the conditions set forth in Sections 2 through 4 below and elsewhere in this Agreement: and (ii) Client meeting the Plan Design conditions identified in the table below, the following guaranteed amounts will be payable to Client during the Term of this Agreement: REBATES • 1 DRUG FORMULARY:1 PARTICIPATING PHARMACIES 1-83 DAYS' SUPPLY • PPO $270.00 per Brand Drug claim PARTICIPATING 1111ARMACIES (84-90 DAYS' SUPPLY • PPO $710.00 per Brand Drug claim MAIL SERVICE PHARMACY • PPO $710.00 per Brand Drug claim SPECIALTY PRODUCTS • PPO 53.405.00 per Brand Drug claim The Extended Days' Supply pricing set forth in this Agreement shall be subject to certain requirements, as follows. Extended Days' Supply shall mean; (1) for all lines of business other than Medicare or EGWP, any supply ofa covered drug of 84 days orgreater; and (2) for Medicare or EGWP, ifapplicable, any supply of a covered drug of 35 days or greater. Certain Participating Pharmacies have agreed to participate in the extended (84 - 90) day supply network ("Maintenance Network") for maintenance drugs. Rebate amounts in the 84 90 Days' Supply row in the table set forth above are applicable only if Client implements a Plan Design that requires Members to fill such days' supply at a Maintenance Network Participating Pharmacy (i.e., Client must implement a Plan Design whereby Members who fill extended days' supply prescriptions at a Participating Pharmacy other than a Maintenance Network Participating Pharmacy do not receive benefit coverage under the Plan for such prescription). If no such Plan Design is implemented, Rebate amounts for such days' supply will be the same as for Prescription Drug Claims for less than an 84 days' supply, and Rebate amounts for an 84 90 days' supply in the table set forth above shall not apply, even if a Maintenance Network Participating Pharmacy is used. Exclusions For Non -Specialty Rebates: Specialty Products, Member Submitted Claims, Subrogation Claims, biosimilar products (excluding Semglee), Exclusive and Limited Distribution Products, vaccines, OTC products (excluding insulin, diabetic strips, and test strips), claims older than 180 days, products filled through in house or 340b Claims, COB claims, and claims pursuant to a 100% Member Copayment plan are not eligible for the guaranteed Rebate amounts set forth in Section D.I above. Exclusions For Specialty Rebates: Member Submitted Claims, Subrogation Claims, biosimilar products (excluding Semglee), Exclusive and Limited Distribution Products, vaccines, OTC products (excluding insulin, diabetic strips, and test strips), claims older than 180 days, products filled through in house or 340b Claims, COB claims, and claims pursuant to a 100% Member Copayment plan are not eligible for the guaranteed Rebate amounts set forth in Section D.1 above. Rebate Payment Terms. Subject to the conditions set forth herein. Administrator will receive from ESI the quarterly Rebate payments within approximately one hundred twenty (120) days following the end of a 17 NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS