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05/20/2025
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05/20/2025
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6/19/2025 1:44:47 PM
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6/19/2025 12:18:07 PM
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Meetings
Meeting Type
BCC Regular Meeting
Document Type
Agenda Packet
Meeting Date
05/20/2025
Meeting Body
Board of County Commissioners
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2. "Vaccine Vendor Transaction Fee" means the data interchange fee that ESI is charged by <br />its third party vendor to convert Vaccine Claims submitted electronically by physicians to <br />NCPDP 5.1 format in order for PBM to process the claim. <br />3. Vaccine Claims shall adjudicate at the lower of U&C or the amounts shown in the table <br />below. In the case of Vaccine Claims, the U&C shall be the retail price charged by a <br />Participating Pharmacy for the particular vaccine, including administration and dispensing <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 be <br />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 />14 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS 106 <br />Participating Pharmacy <br />Participating Pharmacy <br />Member <br />INFLUENZA <br />ALL OTHER VACCINES <br />Vaccine Claims <br />(excluding foreign claims) <br />Vaccine <br />Pass -Through <br />Pass -Through <br />Administration <br />(capped at $20 per vaccine <br />(capped at $25 per vaccine <br />Fee <br />claim) <br />claim and $40 per covid <br />Submitted amount <br />vaccine claim <br />Ingredient Cost <br />Participating Pharmacy <br />Participating Pharmacy <br />Ingredient Cost as set forth <br />Ingredient Cost as set forth <br />Submitted amount <br />in the Agreement <br />in the Agreement <br />Dispensing Fee <br />Participating Pharmacy <br />Participating Pharmacy <br />Dispensing Fee as set forth <br />Dispensing Fee as set forth <br />Submitted amount <br />in the Agreement <br />in the Agreement <br />Administrative <br />Administrative Fee per Prescription Drug Claim as set forth <br />Administrative Fee per <br />Fee/Vaccine <br />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 />14 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS 106 <br />
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