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A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK 2. "Vaccine Vendor Transaction Fee" means the data interchange fee that ESI is charged by its third party vendor to convert Vaccine Claims submitted electronically by physicians to NCPDP 5.1 format in order for PBM to process the claim. 3. Vaccine Claims shall adjudicate at the lower of U&C or the amounts shown in the table below. In the case of Vaccine Claims, the U&C shall be the retail price charged by a Participating Pharmacy for the particular vaccine, including administration and dispensing fees, in a cash transaction on the date the vaccine is dispensed as reported to PBM by the Participating Pharmacy. 4. The Vaccine Administration Fee for Vaccine Claims for Members enrolled in Client's Medicaid programs, if any, will be capped at the maximum reimbursable amount under the state Medicaid program in which the Member is enrolled. 5. All Vaccine Claims will be subject to any Transaction Fees set forth in the Agreement. 6. Vaccine Claims will be charged a program fee of $2.50 per Vaccine Claim (except for Medicare Part D covered Vaccine Claims, if applicable). The Vaccine Program Fee will be billed separately to Client as part of the administrative invoice according to the billing frequency set forth in this Agreement. (b) Commercial (Including Medicaid and Exchange, if applicable) Participating 'h ticipating PaPharmacy Member SubmittedrINFLUENZA ALL VACCINES Vaccine Claims Vaccine Pass -Through Pass -Through (excluding foreign claims) Administration (capped at $20 per vaccine (capped at $25 per vaccine Fee claim) claim and $40 per covid Submitted amount vaccine claim Ingredient Cost Participating Pharmacy Participating Pharmacy Ingredient Cost as set forth Ingredient Cost as set forth Submitted amount in the Agreement in the Agreement Dispensing Fee Participating Pharmacy Participating Pharmacy Dispensing Fee as set forth Dispensing Fee as set forth Submitted amount in the Agreement in the Agreement Administrative Administrative Fee per Prescription Drug Claim as set forth Administrative Fee per Fee/Vaccine in the Agreement Prescription Drug Claim Claim (plus manual claim administrative fee) as set forth in the Agreement Vaccine Program $2.50 per vaccine claim N/A Fee (c) Medicare Part D Covered Vaccine Claims: Medicare Part D Vaccine Claims shall adjudicate at the lower of U&C or the amounts shown in the table below. 14 NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS