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Docusign Envelope ID: 4C195600 -904A-41 DA-A041-3005C422FD42 DocuSign Envelope ID: 7CEFA800-59DE-49DA-8C5B-DBDB41083547 (1/2024 Version) • PPO AWP — 25% GENERIC • PPO AWP — 89% 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, Exclusive or Limited Distribution Products, claims that may be subject to ancillary charges, COVID test kits and antivirals, products filled through in-house pharmacies 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 50.45 dispensing fee GENERIC MAINTENANCE BRAND • PPO NETWORKRETAIL $0.45 dispensing I 1 fee • PPO $0.45 dispensing fee GENERIC ESI MAIL PHARMACY BRAND • PPO $0.45 dispensing fee • PPO 50.00 dispensing fee GENERIC • PPO 50.00 dispensing fee 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, Exclusive or Limited Distribution Products, claims that may be subject to ancillary charges, COVID test kits and antivirals, products filled through in-house pharmacies and COB claims. Claims dispensed at West Virginia pharmacies or Claims subject to NADAC or another pricing benchmark required by law for pharmacy reimbursement may be excluded from dispensing fee guarantees. If applicable, Prescription Drug Claims filled through in-house pharmacies that are no bill, no remit or that have not entered into an ESI pharmacy network agreement are excluded from the discount and dispensing fee guarantees. Dispensing Fees arc inclusive of shipping and handling. If carver rates (i.e., U.S. mail and/or applicable commercial courier services) increase during the Term of this Agreement, the Dispensing Fee guarantees will not be increased to reflect such increase(s). 12 NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS