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Docusign Envelope ID: 4C1 95600-904A-41 DA-A041-3005C422FD42 <br />DocuSign Envelope ID: 7CEFA800-59DE-49DA-8C5B-D8DB41083547 <br />(1/2024 Version) <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 <br />terms specified in the Agreement, including, but not limited to, the annual average <br />ingredient cost discount 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 />1. "Vaccine Claim" means a claim for a Covered Drug which is a vaccine. <br />2. "Vaccine Vendor Transaction Fee" means the data interchange fee that ESI is <br />charged by its third party vendor to convert Vaccine Claims submitted <br />electronically by physicians to NCPDP 5.1 format in order for PBM to process <br />the claim. <br />3. Vaccine Claims shall adjudicate at the lower of U&C or the amounts shown in the <br />table below. In the case of Vaccine Claims, the U&C shall be the retail price <br />charged by a Participating Pharmacy for the particular vaccine, including <br />administration and dispensing fees, in a cash transaction on the date the vaccine <br />is dispensed as reported to PBM by the Participating Pharmacy. <br />4. The Vaccine Administration Fee for Vaccine Claims for Members enrolled in <br />Client's Medicaid programs, if any, will be capped at the maximum reimbursable <br />amount under the 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 <br />Agreement. <br />6. Vaccine Claims will be charged a program fee of $2.50 per Vaccine Claim (except <br />for Medicare Part D covered Vaccine Claims, if applicable). The Vaccine <br />Program Fee will be billed separately to Client as part of the administrative <br />invoice according to the billing frequency set forth in this Agreement. <br />(b) Commercial (Including Medicaid and Exchange, if applicable) <br />16 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />Participating <br />p. <br />INFLUENZA <br />OTHERPharmacy ALL <br />VACCENES <br />Pass -Through <br />(excluding foreign claims) <br />Vaccine <br />Pass -Through <br />Administration <br />(capped at per <br />(capped at $20 per <br />Fee <br />vaccine claim) <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 />Dispensing Fee as set <br />Dispensing Fee as set <br />Submitted amount <br />forth in the A eement <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 />16 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />