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Docusign Envelope ID: 4C195600 -904A-41 DA-A041-3005C422FD42 <br />DocuSign Envelope ID: 7CEFA800-59DE-49DA-8C5B-D8DB41083547 <br />(1/2024 Version) <br />Average Annual Ingredient Cost Guarantee: <br />Limited Distribution Claims (does not apply to AWP — 14.5% <br />gene therapy) <br />(c) Exclusions. For Exclusive Specialty arrangements, the specialty guarantee shall only apply <br />to Plans for which the ESI Specialty Pharmacy is the exclusive pharmacy that may fill <br />Specialty Products for Members, other than Exclusive or Limited Distribution Products not <br />available at the ESI Specialty Pharmacy. In addition to the general exclusions identified <br />above, all non -Specialty Products, and all Exclusive or Limited Distribution Products <br />(except for the Limited Distribution guarantee noted in the chart above) are excluded from <br />the specialty guarantee. Prescription Drug Claims filled through in-house pharmacies that <br />are no bill, no remit or that have not entered into an ESI pharmacy network agreement are <br />excluded from the specialty guarantee. <br />(f) Ancillary Supplies. Equipment, and Services. For Specialty Products needing an additional <br />charge to cover costs of all ASES required to administer the Specialty Products, <br />Administrator, ESI or ESI Specialty Pharmacy will bill at the following standard per diem <br />and nursing fee rates set forth below, maintained and updated by ESI from time to time. If <br />ESI elects to bill Client's medical plan for ASES, Administrator will work with ES] to <br />coordinate the invoicing and payment of ASES through Client's medical plan. If Client's <br />medical plan will not cover the cost of ASES billed through ESI or ESI Specialty <br />Pharmacy, Client shall be responsible for the costs of all ASES. If a Specialty Product <br />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 <br />will timely pay Administrator, and Administrator will timely pay ESI Specialty Pharmacy <br />for such claim pursuant to the rates below. ESI Specialty Pharmacy shall have 360 days <br />from the date of service to submit such electronic or paper claim. <br />Therapeutic Class <br />Brand Name <br />Nursing & Per Diem <br />Immune Deficiency <br />All Immune Deficiency Drugs requiring <br />560.00 / 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 />530.00 / Day <br />Inflammatory Conditions <br />Remicade <br />$60.00 / Infusion <br />Alpha 1 Deficiency <br />All Alpha 1 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 />15 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />