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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />RYAN L. BUTLER, CLERK <br />Prescription Drug Claims Excluded: Specialty Products (other than specialty guarantee), 340B Claims, <br />Subrogation Claims, long term care pharmacy claims, Member Submitted Claims, compounds, OTC <br />products (excluding insulin, diabetic supplies, and test strips), Vaccine Claims, U&C, Exclusive or <br />Limited Distribution Products, claims that may be subject to ancillary charges, COVID test kits, COVID <br />antivirals, Prescription Drug Claims filled through In -House Pharmacies that are No Bill, No Remit or <br />that have not entered into an ESI pharmacy network agreement, and COB claims. <br />(b) Dispensing Fee. Administrator will guarantee an average aggregate annual per Prescription Drug <br />Claim dispensing fee on Client utilization to be calculated as follows: <br />[total dispensing fee of applicable Prescription Drug Claims for the annual period <br />divided by total of applicable Prescription Drug Claims for the annual period] <br />PARTICIPATING' <br />BRAND <br />• PPO <br />$0.45 dispensing <br />fee <br />GENERIC <br />• PPO <br />$0.45 disnensing <br />fee <br />RETAIL MAINTENANCE <br />BRAND <br />O.(84 <br />90 DAYS PP <br />• PPO <br />$0.45 dispensing <br />fee <br />GENERIC <br />ESI MAIL PHARMACY <br />BRAND <br />• PPO <br />$0.45 disnensing <br />fee <br />• PPO <br />$0.00 dispensing <br />fee <br />GENERIC <br />• PPO <br />$0.00 dispensing <br />fee <br />Prescription Drug Claims Excluded: Specialty Products (other than specialty guarantee), 340B Claims, <br />Subrogation Claims, long term care pharmacy claims, Member Submitted Claims, compounds, OTC products <br />(excluding insulin, diabetic supplies, and test strips), Vaccine Claims, U&C, Exclusive or Limited Distribution <br />Products, claims that may be subject to ancillary charges, COVID test kits, COVID antivirals, Prescription <br />Drug Claims filled through In -House Pharmacies that are No Bill, No Remit or that have not entered into an <br />ESI pharmacy network agreement, and COB claims. Claims dispensed at West Virginia pharmacies or Claims <br />subject to NADAC or another pricing benchmark required by law for pharmacy reimbursement may be <br />excluded from dispensing fee guarantees. <br />Dispensing Fees are inclusive of shipping and handling. If carver rates (i.e., U.S. mail and/or applicable <br />commercial courier services) increase during the Term of this Agreement, the Dispensing Fee guarantees will <br />not be increased to reflect such increase(s). <br />When traditional pricing is prohibited, or state law mandates a pharmacy dispensing fee, any charges, <br />expenses, or fees associated with applicable Claims or otherwise assessed by PBM will be passed through to <br />Client by Administrator. <br />Guarantees will be measured and reconciled on an annual basis within 180 days of the end of each Contract <br />Year. The guarantees are annual guarantees - if this Agreement is terminated prior to the completion of the <br />then current contract year or if the applicable Term or Renewal Term being reconciled is less than twelve (12) <br />months in length (hereinafter, a "Partial Contract Year"), then the guarantees will not apply for such Partial <br />10 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />