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A TRUE COPY CERTIFICATION ON LAST PAGE RYAN L. BUTLER, CLERK Ingredient Cost Pass -Through Lower of submitted amount or pharmacy contracted rate Pass -Through Dispensing Fee RETAIL MAINTENANCE NETWORK (84-90 DAYS' SUPPLY Lower of submitted • PPO $812.00 per Brand Drug claim Pass -Through amount or pharmacy Pass -Through $812.00 per Brand Drug claim SPECIALTY PRODUCTS contracted rate • PPO Vendor Transaction Pass-through at ESI cost for Fee N/A N/A Vendor Transaction Fee (currently $3.75, subject to than e D. REBATES 1. Rebate Amounts. Subject to: (i) the conditions set forth in Sections 2 through 4 below and elsewhere in this Agreement; and (ii) Client meeting the Plan Design conditions identified in the table below, the following guaranteed amounts will be payable to Client during the Term of this Agreement: REBATES PER BRAND 1 'PREFERRED PARTICIPATING PHARMACIES 1-83 DAYS'SUPPLY) • PPO $293.00 per Brand Drug claim RETAIL MAINTENANCE NETWORK (84-90 DAYS' SUPPLY • PPO $812.00 per Brand Drug claim MAIL SERVICE PHARMACY • PPO $812.00 per Brand Drug claim SPECIALTY PRODUCTS • PPO $3,421.00 per Brand Drug claim (') Specialty Rebates may be impacted if Client changes the days' supply allotment for specialty claims. The Extended Days' Supply pricing set forth in this Agreement shall be subject to certain requirements, as follows. Extended Days' Supply shall mean; (1) for all lines of business other than Medicare or EGWP, any supply of a covered drug of 84 days or greater; and (2) for Medicare or EGWP, if applicable, any supply of a covered drug of 35 days or greater. Certain Participating Pharmacies have agreed to participate in the extended (84 — 90) day supply network ("Maintenance Network") for maintenance drugs. Rebate amounts in the 84 — 90 Days' Supply row in the table set forth above are applicable only if Client implements a Plan Design that requires Members to fill such days' supply at a Maintenance Network Participating Pharmacy (i.e., Client must implement a Plan Design whereby Members who fill extended days' supply prescriptions at a Participating Pharmacy other than a Maintenance Network Participating Pharmacy do not receive benefit coverage under the Plan for such prescription). If no such Plan Design is implemented, Rebate amounts for such days' supply will be the same as for Prescription Drug Claims for less than an 84 days' supply, and Rebate amounts for an 84 — 90 days' supply in the table set forth above shall not apply, even if a Maintenance Network Participating Pharmacy is used. Exclusions For Non -Specialty Rebates: Specialty Products, Member Submitted Claims, Subrogation Claims, Exclusive or Limited Distribution Products, COVID test kits, COVID antivirals, Vaccine Claims, OTC products (excluding insulin, diabetic supplies, and test strips), Claims Older than 180 days, Claims filled through In -House Pharmacies that do not utilize PBM for rebates, 340b Claims, COB claims, and claims pursuant to a 100% Member Copayment plan are not eligible for the guaranteed Rebate amounts set forth in Section D.1 above. 15 NOT FOR DISTRIBUTION. THE INFORMATION CONTAINED HEREIN IS CONFIDENTIAL, PROPRIETARY AND CONSTITUTES TRADE SECRETS OF ESI AND RXBENEFITS