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A TRUE COPY <br />CERTIFICATION ON LAST PAGE <br />RYAN L. BUTLER, CLERK <br />Specialty Pharmacy will bill at the following standard per diem and nursing fee rates set forth below, <br />maintained and updated by ESI from time to time. If ESI elects to bill Client's medical plan for ASES, <br />Administrator will work with ESI to coordinate the invoicing and payment of ASES through Client's <br />medical plan. If Client's medical plan will not cover the cost of ASES billed through ESI or ESI <br />Specialty 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 Client directly <br />by ESI Specialty Pharmacy instead of being processed through ESI, Client will timely pay <br />Administrator, and Administrator will timely pay ESI Specialty Pharmacy for such claim pursuant to <br />the rates below. ESI Specialty Pharmacy shall have 360 days from the date of service to submit such <br />electronic or paper claim. <br />Class <br />BrandTherapeutic Name <br />Nursing & Per Diem <br />Immune Deficiency <br />All Immune Deficiency Drugs requiring Per <br />$60.00 / Infusion <br />Diem (e.g., Cuvitru, Gammagard, Privigen) <br />Enzyme Deficiency <br />All Enzyme Deficiency Drugs requiring Per <br />$60.00 / Infusion <br />Diem (e.g., Cerezyme, Lumizyme, <br />Nexviazyme) <br />Miscellaneous Specialty <br />Miscellaneous Specialty Conditions Drugs <br />$60.00 / Infusion <br />Conditions <br />requiring Per Diem (e.g., Soliris, Ultomiris) <br />Miscellaneous Specialty <br />Duopa <br />$65.00 / Day <br />Conditions <br />Miscellaneous Specialty <br />Vyvgart <br />$65.00 / Infusion <br />Conditions <br />PAH <br />PAH Drugs requiring Per Diem ( e.g., Flolan, <br />$65.00 / Day <br />Epoprostenol Sodium, and Remodulin) <br />PAH <br />Ventavis <br />$65.00 / Day <br />PAH <br />Tyvaso <br />$30.00 / Day <br />Inflammatory Conditions <br />Inflammatory Conditions Drugs requiring Per <br />$60.00 / Infusion <br />Diem (e.g., Remicade, Avsola, Inflectra) <br />Alpha 1 Deficiency <br />All Alpha 1 Deficiency Drugs requiring Per <br />$55.00 / Infusion <br />Diem (e.g. Aralast NP, Zemaira, Glassia) <br />Cystic Fibrosis <br />Cayston (Replacement Nebulizer) <br />$975.00 <br />Nursing Rates <br />All drugs / therapies requiring nursing <br />$180.00 per initial visit up <br />to two (2) hours/$90.00 per <br />additional hour or a fraction <br />thereof <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 terms <br />specified in the Agreement, including, but not limited to, the annual average ingredient cost discount <br />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 />"Vaccine Claim" means any Claim processed with a GPI -2 of 17 or 18. <br />13 <br />NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY <br />AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS <br />