9-2025 United Healthcare Contract Renewal.pdf

Confidential Information of UnitedHealth Group

October 17, 2024

City of Burleson

141 W Renfro Street

Burleson, TX 76028

RE: January 1, 2025 Financial Renewal under the Administrative Services Agreement (“Agreement”) between

United HealthCare Services, Inc. (“United”) and City of Burleson

This letter is confirmation of your Financial Renewal per the attached exhibit(s).

Nothing shown in this Financial Renewal Letter alters, varies, or affects any of the terms, provisions, or conditions of the Agreement other than as stated herein.

Please feel free to contact your Sales Executive (indicated below) with any questions regarding the attachment(s).

Please file this letter and its attachment(s) with your ASA.

Thank you, Charlene Mancini

Regional Contract Manager

CC: Jessica Kimbrell, Sales Executive;

Attachment(s): Exhibit B, Exhibit C

Renewal 3Q 2024

Agreement No.

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Exhibit B – Fees

These are the Fees Customer agrees to pay to United in exchange for the Services.

Medical Fees

The following financial terms are effective for the period January 1, 2025 through December 31, 2025, unless otherwise specified.

Final Claims Fiduciary: United

Customer acknowledges that UHC Hub products and services are offered and provided by third-party vendors that are not affiliated with United. Customer agrees that United is not responsible or liable in any way for such performance or financial return guarantees. Certain UHC Hub products are subject to state sales Tax. United will invoice and

Customer agrees to pay United for any required Taxes. A third-party vendor’s participation in UHC Hub may terminate in the middle of the Initial Term or Renewal Term of this Agreement. In that instance, the product or service will no longer be provided from that vendor and no further Fees will be charged for that product or service. Fees for

UHC Hub products and services will be paid through a withdrawal from the Bank Account.

ASO MEDICAL FEES

Fees assume an Average Contract Size of 2.19

ASO Fees (PEPM) Current Year 1

Plan Year

01/01/2024 1/1/2025 through through

12/31/2024 12/31/2025

EPO $47.56 $48.51

Rx Rebate Credit -$43.00 -$43.00

Credits

Audit Credit $25,000 N/A

Communication Credit $15,000 $15,000

Wellness Credit $35,000 $45,000

The following services may require an additional cost as noted below:

Additional Disease Management, Specialty and Wellness Programs

(Fees are on a PEPM basis unless specifically noted)

Current Year 1

1/1/2024 1/1/2025 through through

12/31/2024 12/31/2025

Disease Management Programs:

Congestive Heart Failure (VOM)

Included in Personal

Health Support

Included in Personal

Health Support

Chronic Obstructive Pulmonary Disease (VOM)

Coronary Artery Disease (VOM)

Diabetes Program (VOM)

Asthma Program (VOM)

Medical Management Programs

Core Medical Necessity Included Included

Physical Health Solutions:

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Chiropractic Network Included Included

Physical Therapy/Occupational Therapy/Speech Therapy Network Included Included

Complementary Alternative Medicine (CAM) Network Management Included Included

Other Programs/Services:

Behavioral Health Solutions Included Included

Claim Fiduciary Included Included

Third Party Stop Loss Reporting Included Included

The following are not included in the above ASO Fees:

Additional Services Fee

Naviguard $4.75 PEPM

Transplant Resource Services Transplant Cost Negotiation Program $8,333 per negotiation

Payment Integrity (Fees collected through Bank Account):

Enhanced Abuse and Fraud Management Program 22% of recoveries

Advanced Analytics and Recovery Services (AARS) 24% of recoveries

Credit Balance Recovery Program not to exceed 10% of recoveries

Hospital Bill Audit Program not to exceed 22% of savings

Subrogation Services 33.3% of recoveries

Injury Coordination Coverage 33.3% of recoveries

Focused Claim Review 22% of savings

*Naviguard will increase annually by $1.00 PEPM.

The following are included in the ASO Fees (applies to Active and Pre-65 Retiree population only):

• UnitedHealthcare Pharmacy. If the pharmacy is carved out to another vendor, the ASO fees and Credits are subject to change.

• eServices Reporting - (interactive fully Web-based reporting)

• Federal External Review Program (third level appeals) - our Medical ASO fee includes a maximum of 5 reviews.

Reviews in excess of this limit will be charged at $500 per review.

• Advocate4Me Customer Service Model that provides participants with access to a one-stop advocacy resource for an unprecedented range of needs, including support and access to services across medical benefits, claims, pharmacy, clinical, incentives, and more.

• Customer Service, our quoted customer service model offers members a high-touch, personal guide who provides support in navigating benefits, understanding payment options, resolving claim issues and working through the health care system. In addition to acting as a one-stop shop where members can be directed to the most appropriate existing services, representatives can provide additional information relevant to personal needs and take ownership of inquires end-to-end. For those not resolved during the initial call, customer service representatives take ownership until resolution including call back to the member.

• Employer Internet Solution – www.employereservices.com

• Our quote includes the management of over 100 disease states/conditions, as part of our Personal Health Support

(PHS) program. We believe this approach will adequately address the clinical conditions present within the population - though we are open to discussing and proposing alternative programs, should clinical prevalence indicate an appropriate ROI.

• Consumer Activation, including basic navigation guide, health statements with individualized messaging, advanced concierge call services, and access to member portal with consumer activation messaging

• UnitedHealthcare will duplicate requested plan of benefits in principle and in a manner compatible with our understanding of the basic plan designs. Our quotation may be adjusted contingent upon review of all Medical plan design specifics. Our fees may be adjusted, or changes to the plans may be required to enable us to administer claim payments.

Pricing Assumptions

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• The Plan or its sponsor is responsible for state or federal surcharges, assessments, or similar taxes or fees imposed by governmental entities or agencies on the Plan, Plan Sponsor or us, including but not limited to those imposed pursuant to the Patient Protection and Affordable Care Act of 2010 (PPACA), as amended from time to time. This includes responsibility for determining the amount due, funding, and remitting the PPACA Transitional Reinsurance fee and the PCORI fee which are remitted to the government (federal and/or state).

• The fees quoted do not include state or federal surcharges, assessments, or similar taxes/fees imposed by governmental entities or agencies on the Plan, Plan Sponsor or UnitedHealthcare. We reserve the right to adjust the rates (i) in the event of any changes in federal, state or other applicable legislation or regulation; (ii) in the event of any changes in plan design or procedures required by the applicable regulatory authority or by the sponsor; and (iii) as otherwise permitted in the Administrative Services Agreement.

• The administrative fees set forth herein do not include fees related to the requirements set forth in the Consolidated Appropriations Act, 2021, including the No Surprises Act. Additional fees for these new regulatory requirements will be provided at a future date once regulatory guidance is received and final compliance requirements are determined.

• UnitedHealthcare reserves the right to revise this quotation under the following circumstances:

• The total number of enrolled medical employees varies by more than 10 percent from the assumed medical enrollment of 390

• The average contract size, defined as the total number of enrolled employees plus dependents divided by the total number of enrolled employees, varies by 10 percent or more from the assumed average contract size of 2.19.

• The benefits or service requirements requested and/or quoted change prior to or after the effective date.

• In the event of any changes in federal, state or other applicable legislation or regulation that require changes to this quotation.

• In the event of any changes in plan design required by the applicable regulatory authority or by the Plan sponsor.

• In the event that any taxes, surcharges, assessments, or similar charges are imposed by governmental entities or agencies on the Plan or UnitedHealthcare, in its role as administrator or insurer.

• As otherwise permitted in our Administrative Services Agreement

• Our quotation excludes the processing of runout claims upon the termination of our contract.

• If pharmacy benefits are carved out the ASO fees quoted above may be revised.

• Customer will only receive Rebates to the extent that Rebates are actually received by United. For example, if a government action or a major change in pharmaceutical industry practices eliminates or materially reduces manufacturer Rebate programs, Customer’s payment amount may be reduced or eliminated. In such event, United shall promptly notify Customer and revise or eliminate such payment effective with the date of the reduction or elimination in Rebate payments. In addition, reduction or elimination of Rebates in this event shall constitute a change in the Agreement as described in the Fees Section such that United has the right to increase the fees for the Pharmacy Benefits Management services or increase the percentage of Rebate dollars retained by United.

• We reserve the right to adjust our rebate guarantee if changes made to our prescription drug list (PDL) for the purpose of achieving lower net drug cost for CITY OF BURLESON and our other ASO customers result in significant reductions to the rebate level.

• Quoted fees include UHC retention of all medical benefit Rx rebates

• Commissions are excluded.

• This quotation assumes UnitedHealthcare will retain claim fiduciary responsibility

• United will provide a Communication Credit, Wellness Credit, Audit Credit to help CITY OF BURLESON mitigate costs associated with communication to Participants, additional wellness services from United, Audit

These credits are available as follows:

• The parties must have an executed Agreement.

• The first month of service fees under the Agreement has been received by United.

• CITY OF BURLESON’s enrollment with United must always exceed 339 Employees.

• Credits must be used between 01/01/2025 and 01/01/2026. Any Credits not used during this time period are forfeit.

• Upon request from CITY OF BURLESON, a credit will be issued in United’s fee billing system.

• Upon presentation of receipts for costs, a credit will be issued in United’s fee billing system in the amount of the receipted expenses, total amount not to exceed the full credit.

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• If CITY OF BURLESON terminates the Agreement prior to 12/31/2025, CITY OF BURLESON will repay United a prorated portion of the credit paid in the year of termination based on the termination date. Credits in prior years are not subject to repayment. All unpaid credits are forfeit.

• If enrollment with United falls below the enrollment threshold, CITY OF BURLESON will repay

United an amount proportional to the enrollment reduction based on the amount of the credit paid at the time enrollment falls below the threshold.

• The amount of the credit not yet paid is reduced proportional to the enrollment reduction.

• If during the course of the first year unforeseen or additional expense items arise related to the CITY OF

BURLESON implementation, UHC reserves the right to use a portion of this credit to offset such expenses.

Service Description

Advanced Analytics and Recovery

• United’s large-scale analytics to identify additional recovery opportunities.

• Claims re-examined every month for up to 12 months.

• Post-adjudicated claims.

Coordination of Benefits (“COB”)

• Verify primary/secondary payer accuracy.

• Identify claims to be investigated using a layered approach to identify other primary payers:

1. Eligibility match to other commercial payers.

2. Eligibility match to Medicare.

• Correct pre-adjudicated claims prior to claim payment.

• Update claims systems with other primary/secondary payers’ information.

• COB indicators set to edit subsequent claims with primary/secondary payers’ information.

Credit Balance Recovery

• Review, validate, and recover credit balances (dollars) on existing patient accounts through a combination of analysis and technology.

• On-site at hospitals and facilities.

• Post-adjudicated claims.

Focused Claim Review

• Review of claims for inappropriate billing of services not documented in clinical notes.

• Board certified, same-specialty medical directors.

Pre-adjudicated claims or post-adjudicated claims.

Fraud, Waste, and Abuse Management

• Detection and recovery of wasteful, abusive, and/or fraudulent claims.

• Search claims for patterns which indicate possible waste or error by identifying specific claims for additional review.

• Evaluate claims to identify inappropriate levels of care, coding, and/or resource utilization.

• Management can include pre-adjudicated claims or post-adjudicated claims.

Hospital Bill and Premium Audit

• In-depth review of hospital medical records or other related documentation compared to claimed amounts to ensure billing accuracy.

• Post-adjudicated claims.

Third-Party Liability – Subrogation and Injury Coverage Coordination

• Services to prevent the payment of Plan benefits, or recover Plan benefits, which should be paid by a third party.

• Does not include benefits paid in connection with coordination of benefits, Medicare, or other Overpayments.

• Pre-adjudicated claims or post-adjudicated claims.

• Customer will not engage any entity except United to provide such services without prior United approval.

Litigation and Arbitration Fees for Recoveries

• Litigation or arbitration to recover Overpayments and other Plan recovery opportunities.

• Outside attorneys’ fees and costs directly incurred with litigation or arbitration.

• Pre-adjudicated claims or post-adjudicated claims.

Naviguard Program

• Offers reimbursement methodologies for emergent and non-emergent out of network claims which calculates allowed amounts based on what a healthcare provider generally accepts for the same or similar service.

• Includes an advocacy component where Participants can access resources, and on-line tools and materials to help

Participants stay in network and where assistance is provided in explaining reimbursement methodologies.

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• For claims above a threshold established by United, the advocacy component includes United negotiating with a provider on behalf of a Participant with respect to Participant’s balance billed amount (e.g., non-emergent, choice claim).

• If the provider objects to what it was paid from the application of the allowed amount, or member contacts United for support with resolving a balance bill, United will increase compensation for a particular claim if: (a) United reasonably concludes that the particular facts and circumstances related to a claim provide justification for reimbursement greater than that which would result from the application of the allowed amount, and (b) United believes that it would serve the best interests of the Plan and its Participants (including interests in avoiding costs and expenses of disputes over payment of claims).

• Fees are based on the Savings Obtained, which is the amount billed by a health care provider minus the final amount paid to the health care provider pursuant to the out-of-network program selected by the Plan which includes amounts payable by the Participant.

The interest rate on unpaid Fees and underfunding the Bank Account is the Prime rate plus 4%.

For clinical support. if applicable, Customer will pay a Fee for United’s services, equal to 2.5% of chiropractic allowed expenses, whether in or out of network.

Disclosure: A United affiliate provides payment services to the healthcare industry and offers medical providers with various payment methods and options, including electronic payments, virtual cards and checks. Some options are available to medical providers for a fee and may result in the receipt of transaction fees or other compensation (e.g., 1% to 3% of the total transaction amount, or at the election of the provider a per transaction fee of up to $10) by a United affiliate. This has no impact on the Fees paid by Customer under this Agreement.

Dental Fees

The following financial terms are effective for the period January 1, 2025 through December 31, 2025, unless otherwise specified.

Contract Basis: ASO

$4.15 per Employee per month.

Dental Assumptions

Rates listed above assume the plan designs quoted. Rates may change, if plan design changes.

Our contract covers only those procedures performed in the United States.

Please contact your sales representative for more details on the network quoted in your proposal.

Run-In Claims are not Paid.

Fees include 12 months of run out claims. Additional months are available at an additional cost.

The In- and Out-of-Network Plan Deductibles, Maximums and Lifetime Ortho Maximums are combined.

* Please contact your sales representative to confirm specific plan Restorations (Amalgams or Composite) coverage.

Quote is based on total group Average Contract Size (ACS) of 2.13 Quote is based on total group of 425 Employees and 874 Members.

United Healthcare reserves the right to adjust the above rates should enrollment or ACS fluctuate by +/- 10%.

This quote assumes UnitedHealthcare will retain claim fiduciary responsibility.

Digital ID cards will be available on-line, upon initial enrollment, for employees enrolled in PPO, INO and Indemnity plans. Plastic

ID cards will be issued, upon initial enrollment, for employees enrolled in Direct Compensation, Select Managed Care and DHMO plans.

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Exhibit E – Guarantees

The Fees payable by Customer under this Agreement will be adjusted through a credit to Customer’s Fees in accordance with the guarantees set forth below unless otherwise defined in the guarantee. Unless otherwise specified, these guarantees are effective for the period beginning January 1, 2025 through December 31, 2025 (“Guarantee

Period”). With respect to the aspects of United’s performance addressed in this exhibit, these Fee adjustments are

Customer’s exclusive financial remedies.

United shall not be required to meet any of the guarantees provided for in this Agreement or amendments thereto to the extent United’s failure is due to Customer’s actions or inactions or if United fails to meet these standards due to fire, embargo, strike, war, accident, act of God, acts of terrorism or United’s required compliance with any law, regulation, or governmental agency mandate or anything beyond United’s reasonable control.

Prior to the end of the Guarantee Period, and on the condition that this Agreement remains in force, United may specify to Customer in writing new guarantees for the subsequent Guarantee Period. If United specifies new guarantees, United will also provide Customer with a new Exhibit that will replace this Exhibit for that subsequent Guarantee

Period.

Claim is defined as an initial and complete written request for payment of a Plan benefit made by an enrollee, physician, or other healthcare provider on an accepted format. Unless stated otherwise, the claims are limited to medical claims processed through the claims systems. Claims processed and products administered through any other system, including claims for other products such as vision, dental, flexible spending accounts, health reimbursement accounts, health savings accounts, or pharmacy coverage, are not included in the calculation of the measurements.

Also, services provided under capitated arrangements are not processed as a typical claim, therefore capitated payments are not included in the measurements.

In the event any of the terms herein are inconsistent with the requirements of any federal, state or other applicable law or regulation, then the inconsistent terms will be null and void and United will have the right to revise, reprice or revoke this arrangement.

PharmacyA12:E44 Financials

Definition Contracted pharmacy rates that will be delivered to You.

Measurement 01/01/2025 and Criteria Combined Discount Guarantee - Standard Select/CVS Network

Retail Brand, Average Wholesale Price (AWP) less 20.00%

Retail Brand -- 90 Day Supply, AWP less 24.00%

Retail Generic - 30 and 90 Day Supply, AWP less 83.00%

Mail Order Brand, AWP less 26.70%

Mail Order Generic, AWP less 85.00%

The Guaranteed Discount amount will be determined by multiplying the AWP by the guaranteed discount off AWP by each component and adding the amounts together.

Dispensing Fees - Standard Select/CVS Network

Retail Brand - 30 Day $0.50

Retail Brand -- 90 Day Supply $0.25

Retail Generic - 30 Day $0.50

Retail Generic -- 90 Day Supply $0.25

Dispensing fee totals are calculated by multiplying the actual scripts for each type by the contracted rate for that script type.

Fixed Rebate Guarantee (Traditional PDL)

Basis, per script Brand

Retail - 30 and 90 Day $461.68

Mail Order $897.83

Specialty Included In

Retail

Included In

Retail

Credits and Allowances

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Administrative Fee Credit (PEPM) $43.00

Level Customer Specific

Period Annually

Payment Period Annually

Payment

Amount --

Discounts

The amount the actual discounts are less than the combined guaranteed Retail, Mail, and Specialty discount amount.

Payment

Amount --

Dispensing Fees

The amount the combined actual dispensing fee exceeds the combined contracted dispensing fee.

Payment

Amount --

Rebates

The amount the combined actual Rebate amount is less than the combined guaranteed Rebate amount.

Conditions Discount & Dispense Fee Specific Conditions

• Discounts are based on actual Network Pharmacy brand and generic usage of retail and mail order drugs. The guaranteed discount amount will be determined by multiplying the AWP by the contracted discount rate off AWP by component.

• Does not apply to items covered under the Plan for which no AWP measure exists.

• Discounts calculated based on AWP less the ingredient cost; discount percentages are the discounts divided by the AWP. Discounts for retail and mail order generic prescriptions represent the average

AWP based on savings off Maximum Allowable Cost (MAC) pricing for MAC generics and percentage discount savings off AWP for non-MAC generics. All other discounts represent the percentage discount savings off of AWP.

• The arrangement excludes generic medications launched as an 'at-risk' product, generic medication with pending litigation, compound drugs, retail out of network claims, mail order drugs (for dispensing fee arrangement) and Indian Health Service Claims.

• The Arrangement excludes usual & customary claims, vaccines, long term care facility claims, over-the-counter claims.

• The Arrangement includes veterans’ affairs facility claims.

• The 90 day supply Retail guarantee includes drugs dispensed for 84 days or greater.

• The Mail Order guarantee includes drugs dispensed for 46 days or greater.

• When a drug is identified as a brand name drug, it will be considered a brand name drug for the calculation of discount guarantees. When a drug is identified as a generic drug, it will be considered a generic drug for the calculation of discount guarantees.

• Specialty drugs dispensed outside United's specialty Pharmacy Network are included in the retail guarantees. Specialty drugs dispensed through United's specialty Pharmacy Network are excluded from the Retail and Mail guarantees.

• Drugs in the following Specialty therapeutic categories are included in the retail guarantees: None.

Rebate Specific Conditions

• Assumes implementation of United's Traditional PDL

• Client directed deviations from the PDL and PDL exclusions or uptiers, or clinical programs may result in changes to pricing and guarantees, which will be factored in at the time of rebate payment and/or reconciliation.

• Calculation of the guaranteed rebate amount will exclude ineligible claims including claims where the plan is not the primary payer (e.g., coordination of benefits and subrogation claims), claims approved by formulary exception, claims not covered by Customer's benefit design or PDL, claims subject to

340B pricing, long term care or federal government pharmacies, claims for non-FDA approved products, compound drugs, consumer card or discount card program claims and direct member reimbursement claims.

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• Rebate guarantee payments or reconciliations may be adjusted in the event of a change impacting the level of Rebates due to the introduction of therapeutically equivalent, lower Rebate drugs (e.g.

biosimilar, authorized brand alternative, lower cost non-Generic Drug alternative) or the reduction of

Wholesale Acquisition Cost on a Brand Drug subject to Rebates. In the event a payment or reconciliation adjustment is required, such adjustment will be based on the difference between a) pharmaceutical manufacturer revenue prior to the introduction of the lower Rebate drugs and b) the actual pharmaceutical manufacturer revenue received after the introduction of the lower Rebate drugs.

Such adjustment does not apply to Generic Drugs that launch after the Brand Drug no longer has patent protection.

United reserves the right to modify or eliminate this arrangement as follows based upon changes in

Rebates:

• if changes made to United's PDL, for the purpose of achieving a lower net drug cost for Customer and

United's other ASO customers, result in significant reductions to the Rebate level

• in the event that there are material deviations to the anticipated timing of drugs that will come off patent and no longer generate Rebates

• if there is a change impacting the availability or amount of Rebates offered by drug manufacturer(s), including changes related to the elimination or material modification of a drug manufacturer(s) historic models or practices related to the provision of Rebates

• United will pay Fixed Rebates consistent with the Agreement. To the extent Rebates paid to United exceed the Fixed Rebate amount, We will retain the excess, including any Rebates United may earn on prescription drug products in any tiers not included in this arrangement and any related interest.

• Specialty rebates are included in the guaranteed retail per-script rebates above.

• Rebate Administrative Fee: United maintains systems and processes necessary for managing and administering Rebate programs. As consideration for these efforts, pharmaceutical manufacturers pay

United administrative fees in addition to Rebates. Rebate Administration fees are included in the guaranteed rebate arrangement.

• If Customer terminates pharmacy benefit services with United prior to the end of the Pharmacy

Pricing Term, United will retain any and all pending or future Rebates payable under the Agreement as of the effective date of the termination of pharmacy benefit services.

• Drugs in the following Specialty therapeutic categories are included in the retail per-Brand guarantees: None.

• Vaccines are excluded from the claim counts.

Credits and Allowances

• Administrative Fee Credit: In addition to the guaranteed Rebates, Customer will receive an administrative fee credit. Under this arrangement, Rebates retained by United are used to lower the medical administration fee.

General Conditions

• All pricing guarantees shall remain in effect for the entire contract period of 01/01/2025 through

12/31/2025 ("Pharmacy Pricing Term"). Each twelve month period is a Guarantee Period.

• Specialty drugs typically covered under the medical benefit (administered / handled by a provider, administered in a physician's office, ambulatory or home infusion), and/or transitioned to the pharmacy benefit, are excluded from all guarantees.

• Drugs, products, supplies approved, covered and/or prescribed for the diagnosis, treatment or prevention of COVID-19 are excluded from all guarantees.

• On mail order drugs, specialty drugs, and retail pharmacy drugs and services including dispensing fees, United will retain the difference between what United reimburses the Network Pharmacy and

Customer's payment for a prescription drug product or service.

• Pricing and guarantees assume enrollment of 353 Employees and 779 Participants; pricing and guarantees may be revised or withdrawn if actual enrollment varies by 10% or more from assumptions.

• The lessor of three logic (non-ZBL) will apply to Participant payments. Participants pay the lessor of the discounted price, the usual and customary charge or the cost share amount.

• All pricing guarantees require the selection of United as the exclusive mail provider.

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United will have no financial guarantee obligation under the Agreement for any partial Guarantee

Period if Customer terminates with an effective date prior to the end of the Pharmacy Pricing Term.

• United reserves the right to revise or revoke this arrangement if: a) changes in federal, state or other applicable law or regulation require modifications; b) there are material changes to the AWP as published by the pricing agency that establishes the AWP as used in these arrangements; c) Customer makes benefit changes that impact the arrangements; d) there is a material industry change in pricing methodologies resulting in a new source or benchmark; e) it is not accepted within ninety (90) days of the issuance of our initial quote; f) if Customer changes their mail service benefit; g) Customer utilizes a vendor, that facilitates steering members to different drugs or pharmacies to the extent these services impact the financial guarantees under this Agreement.

Brand / Generic Reconciliation Definition

• Brand Drug: An FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy

Study Implementation) drug, or product, which is manufactured and distributed by an innovator drug company, or its licensee , set forth in Medi-Span’s National Drug Data File as a brand drug identified by all of the products meeting at least one of the following criteria:

- Medi-Span Multi-Source Code ("MSC") is equal to M, O, or N.

• Generic Drug: An FDA approved drug, or a drug that is designated by FDA a DESI (Drug Efficacy

Study Implementation) drug, or product, that is therapeutically equivalent to other pharmaceutically equivalent products, as set forth in Medi-Span’s National Drug Data File as a generic drug identified by all products meeting at least one of the following criteria:

- Medi-Span Multi-Source Code ("MSC") is equal to Y.

TRRX (12/2022)

Specialty Pharmacy

Specialty Pharmacy Discount Guarantee

Definition Specialty drug discount level based on actual specialty drug utilization for the specialty drugs dispensed through United's specialty Pharmacy Network. United reserves the right to change the designation of a drug from specialty to non-specialty based on market conditions.

Measurement Discount targets for individual drugs dispensed through United's specialty Pharmacy Network. See chart below.

Specialty drugs not included on the list below and dispensed through United's specialty Pharmacy

Network will be guaranteed at a discount of 14.0%.

Criteria Actual utilization, using Average Wholesale Price (AWP) in dollars, using our data, of specialty drugs through our specialty Pharmacy Network will be multiplied against the discount targets for the individual drugs to determine the overall discount target dollars. This total will be compared to actual discounts achieved for these drugs during the Guarantee Period.

The overall discount target dollars may be adjusted based on utilization of unlisted drugs to which the separate 14.0% discount applies. This total will be compared to actual discounts achieved for these drugs during the Guarantee Period.

Level Customer Specific

Period Annual

Payment Period Annual

Payment

Amount The amount the actual discounts are less than the combined guaranteed Retail, Mail, and Specialty discount amount.

Conditions • Discounts calculated based on the AWP less the ingredient cost; discount percentages are the discounts divided by the AWP. Discounts for retail generic prescriptions represent the average savings off AWP based on Maximum Allowable Cost (MAC) pricing for MAC generics and percentage discount savings off AWP for non-MAC generics. All other discounts represent the percentage discount savings off of AWP.

• Specialty drugs dispensed outside United's specialty Pharmacy Network, drugs for which no AWP measure exists and non-drug items are excluded.

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• Listed drugs which cease to be defined as specialty drugs during the Guarantee Period will be reconciled outside of the Specialty Pharmacy guarantee in the channel in which they are dispensed (retail or mail order).

• Specialty drugs typically covered under the medical benefit (administered / handled by a provider, administered in a physician's office, ambulatory or home infusion), and/or transitioned to the pharmacy benefit, are excluded from all guarantees.

• United reserves the right to revise or revoke this guarantee if:

a) material changes in federal, state or other applicable law or regulation require modifications;

b) there are material changes to the AWP as published by the pricing agency that establishes the

AWP as used in this guarantee;

c) Customer makes benefit changes that impact the guarantee;

d) there is a material industry change in pricing methodologies resulting in a new source or benchmark;

• On specialty drugs, United will retain the difference between what United reimburses the Network

Pharmacy and Customer's payment for a prescription drug product or service.

Specialty Drug

Category Drug Name

LDD

Indic ator

Guarantee

Pricing

(AWP-%)

Specialty Drug

Category Drug Name

LDD

Indic ator

Guarantee

Pricing

(AWP-%)

ANEMIA ARANESP No 14.50%

INFLAMMATORY

CONDITIONS HUMIRA No 16.10%

ANEMIA EPOGEN No 13.30%

INFLAMMATORY

CONDITIONS ILUMYA No 14.10%

ANEMIA PROCRIT No 13.60%

INFLAMMATORY

CONDITIONS KEVZARA No 9.90%

ANEMIA RETACRIT No 14.10%

INFLAMMATORY

CONDITIONS KINERET Yes 13.50%

ANTICONVULSAN

T DIACOMIT Yes 12.50%

INFLAMMATORY

CONDITIONS OLUMIANT Yes 12.50%

ANTICONVULSAN

T EPIDIOLEX Yes 12.50%

INFLAMMATORY

CONDITIONS OPZELURA No 10.90%

ANTICONVULSAN

T FINTEPLA Yes 10.40%

INFLAMMATORY

CONDITIONS ORENCIA No 14.20%

ANTIHYPERLIPID

EMIC JUXTAPID Yes 13.20%

INFLAMMATORY

CONDITIONS OTEZLA No 14.00%

ANTI-INFECTIVE ARIKAYCE Yes 13.00%

INFLAMMATORY

CONDITIONS RIDAURA No 14.10%

ANTI-INFECTIVE DARAPRIM Yes 12.50%

INFLAMMATORY

CONDITIONS RINVOQ No 14.10%

ANTI-INFECTIVE

PYRIMETHAMI

NE Yes 12.50%

INFLAMMATORY

CONDITIONS SILIQ Yes 11.40%

ANTIVIRAL LIVTENCITY Yes 13.00%

INFLAMMATORY

CONDITIONS SIMPONI No 14.10%

ASTHMA FASENRA Yes 12.50%

INFLAMMATORY

CONDITIONS SKYRIZI No 18.10%

ASTHMA NUCALA Yes 12.50%

INFLAMMATORY

CONDITIONS STELARA No 16.10%

ASTHMA XOLAIR Yes 12.50%

INFLAMMATORY

CONDITIONS TALTZ No 11.40%

CARDIOVASCULA

R DROXIDOPA Yes 33.00%

INFLAMMATORY

CONDITIONS TREMFYA No 14.10%

CARDIOVASCULA

R NORTHERA Yes 14.00%

INFLAMMATORY

CONDITIONS XELJANZ No 14.10%

CARDIOVASCULA

R VYNDAMAX Yes 15.20%

INFLAMMATORY

CONDITIONS XELJANZ XR No 14.10%

CARDIOVASCULA

R VYNDAQEL Yes 12.50% IRON OVERLOAD DEFERASIROX Yes 66.40%

CNS AGENTS AUSTEDO No 13.50% IRON OVERLOAD EXJADE Yes 12.10%

CNS AGENTS ENSPRYNG Yes 11.90% IRON OVERLOAD FERRIPROX Yes 12.50%

CNS AGENTS EXSERVAN Yes 13.50% IRON OVERLOAD JADENU No 13.50%

CNS AGENTS FIRDAPSE Yes 10.40% LIVER DISEASE OCALIVA Yes 15.00%

Page | 12

CNS AGENTS HETLIOZ Yes

14.00%

MONOCLONAL

ANTIBODY

MISCELLANEOU

S

BENLYSTA Yes

13.50%

CNS AGENTS INGREZZA Yes 13.00%

MOOD

DISORDER

DRUGS SPRAVATO No 13.50%

CNS AGENTS RILUTEK No 13.50%

MULTIPLE

SCLEROSIS AMPYRA Yes 11.70%

CNS AGENTS RILUZOLE No 92.60%

MULTIPLE

SCLEROSIS AUBAGIO Yes 12.50%

CNS AGENTS RUZURGI No 11.40%

MULTIPLE

SCLEROSIS AVONEX No 14.00%

CNS AGENTS SABRIL Yes 16.10%

MULTIPLE

SCLEROSIS BAFIERTAM Yes 14.00%

CNS AGENTS

TETRABENAZIN

E No 48.50%

MULTIPLE

SCLEROSIS BETASERON No 14.10%

CNS AGENTS TIGLUTIK Yes 10.40%

MULTIPLE

SCLEROSIS COPAXONE No 14.70%

CNS AGENTS VIGABATRIN No 17.60%

MULTIPLE

SCLEROSIS DALFAMPRIDIN Yes 92.80%

CNS AGENTS VIGADRONE Yes 16.60%

MULTIPLE

SCLEROSIS

DIMETHYL

FUMARATE Yes 79.40%

CNS AGENTS XENAZINE Yes 15.50%

MULTIPLE

SCLEROSIS EXTAVIA No 14.10%

CNS AGENTS XYREM Yes 6.30%

MULTIPLE

SCLEROSIS GILENYA No 14.00%

CNS AGENTS XYWAV Yes 7.30%

MULTIPLE

SCLEROSIS GLATIRAMER No 79.40%

CYSTIC FIBROSIS BETHKIS No 11.40%

MULTIPLE

SCLEROSIS GLATOPA No 79.40%

CYSTIC FIBROSIS CAYSTON Yes 14.50%

MULTIPLE

SCLEROSIS KESIMPTA No 14.00%

CYSTIC FIBROSIS KALYDECO Yes 13.50%

MULTIPLE

SCLEROSIS MAVENCLAD Yes 14.00%

CYSTIC FIBROSIS KITABIS PAK No 12.50%

MULTIPLE

SCLEROSIS MAYZENT Yes 14.00%

CYSTIC FIBROSIS ORKAMBI Yes 13.50%

MULTIPLE

SCLEROSIS PLEGRIDY Yes 13.50%

CYSTIC FIBROSIS PULMOZYME Yes 15.00%

MULTIPLE

SCLEROSIS PONVORY Yes 10.90%

CYSTIC FIBROSIS SYMDEKO Yes 13.50%

MULTIPLE

SCLEROSIS REBIF No 14.00%

CYSTIC FIBROSIS TOBI No 13.80%

MULTIPLE

SCLEROSIS REBIF REBIDOSE No 14.00%

CYSTIC FIBROSIS

TOBI

PODHALER No 13.80%

MULTIPLE

SCLEROSIS TECFIDERA Yes 14.00%

CYSTIC FIBROSIS TOBRAMYCIN No 69.10%

MULTIPLE

SCLEROSIS VUMERITY Yes 12.50%

CYSTIC FIBROSIS TRIKAFTA Yes 13.50%

MULTIPLE

SCLEROSIS ZEPOSIA Yes 12.50%

ENDOCRINE BUPHENYL No 14.80%

MUSCULOSKELE

TAL AGENTS EVRYSDI Yes 7.30%

ENDOCRINE BYNFEZIA No 8.30%

MUSCULOSKELE

TAL AGENTS VOXZOGO Yes 11.40%

ENDOCRINE CARBAGLU Yes 7.30% NARCOLEPSY WAKIX Yes 13.50%

ENDOCRINE CHENODAL Yes 9.40% NEUTROPENIA FULPHILA No 13.80%

ENDOCRINE CLOVIQUE No 33.00% NEUTROPENIA GRANIX No 13.80%

ENDOCRINE CORTROPHIN Yes 10.40% NEUTROPENIA LEUKINE No 13.80%

ENDOCRINE CUPRIMINE No 14.10% NEUTROPENIA NEULASTA No 13.80%

ENDOCRINE CYSTADANE Yes 10.40% NEUTROPENIA NEUPOGEN No 13.80%

ENDOCRINE CYSTADROPS Yes 10.40% NEUTROPENIA NIVESTYM No 13.80%

ENDOCRINE CYSTARAN Yes 13.00% NEUTROPENIA NYVEPRIA No 11.40%

ENDOCRINE

DEPEN

TITRATABS No 14.00% NEUTROPENIA UDENYCA No 13.80%

Page | 13

ENDOCRINE D-PENAMINE No 13.00% NEUTROPENIA ZARXIO No 13.80%

ENDOCRINE EGRIFTA Yes 13.50% NEUTROPENIA ZIEXTENZO No 13.50%

ENDOCRINE FIRMAGON No 13.50%

ONCOLOGY -

INJECTABLE ELIGARD No 12.60%

ENDOCRINE GATTEX Yes 14.80%

ONCOLOGY -

INJECTABLE INTRON A Yes 13.50%

ENDOCRINE H.P. ACTHAR Yes 13.50%

ONCOLOGY -

INJECTABLE LEUPROLIDE No 62.90%

ENDOCRINE IMCIVREE Yes 13.50%

ONCOLOGY -

INJECTABLE SYNRIBO Yes 13.80%

ENDOCRINE ISTURISA Yes 10.40%

ONCOLOGY -

ORAL ABIRATERONE No 82.50%

ENDOCRINE JYNARQUE Yes 12.50%

ONCOLOGY -

ORAL AFINITOR No 14.10%

ENDOCRINE KEVEYIS Yes 13.00%

ONCOLOGY -

ORAL

AFINITOR

DISPERZ No 14.10%

ENDOCRINE KORLYM Yes 11.40%

ONCOLOGY -

ORAL ALECENSA Yes 14.10%

ENDOCRINE KUVAN Yes 12.70%

ONCOLOGY -

ORAL ALKERAN No 15.40%

ENDOCRINE LANREOTIDE Yes 10.40%

ONCOLOGY -

ORAL ALUNBRIG Yes 11.90%

ENDOCRINE MYALEPT Yes 7.30%

ONCOLOGY -

ORAL AYVAKIT Yes 14.50%

ENDOCRINE MYCAPSSA Yes 11.40%

ONCOLOGY -

ORAL BALVERSA Yes 13.50%

ENDOCRINE NATPARA Yes 13.20%

ONCOLOGY -

ORAL BEXAROTENE No 33.50%

ENDOCRINE NITYR Yes 13.00%

ONCOLOGY -

ORAL BOSULIF Yes 13.50%

ENDOCRINE

OCTREOTIDE

ACETATE No 56.80%

ONCOLOGY -

ORAL BRAFTOVI Yes 14.00%

ENDOCRINE

PENICILLAMIN

E No 33.00%

ONCOLOGY -

ORAL BRUKINSA Yes 13.00%

ENDOCRINE PROCYSBI Yes 7.30%

ONCOLOGY -

ORAL CABOMETYX Yes 12.50%

ENDOCRINE RAVICTI Yes 15.00%

ONCOLOGY -

ORAL CALQUENCE Yes 13.50%

ENDOCRINE SAMSCA Yes 13.50%

ONCOLOGY -

ORAL CAPECITABINE No 82.50%

ENDOCRINE SANDOSTATIN No 13.80%

ONCOLOGY -

ORAL CAPRELSA Yes 9.40%

ENDOCRINE SAPROPTERIN Yes 41.30%

ONCOLOGY -

ORAL COMETRIQ Yes 13.00%

ENDOCRINE SIGNIFOR Yes 7.30%

ONCOLOGY -

ORAL COPIKTRA Yes 14.50%

ENDOCRINE

SODIUM

PHENYLBUTYR

ATE No 33.00%

ONCOLOGY -

ORAL COTELLIC Yes 12.50%

ENDOCRINE

SOMATULINE

DEPOT Yes 13.50%

ONCOLOGY -

ORAL DAURISMO Yes 12.50%

ENDOCRINE SOMAVERT Yes 10.60%

ONCOLOGY -

ORAL ERIVEDGE Yes 12.50%

ENDOCRINE SYPRINE No 13.50%

ONCOLOGY -

ORAL ERLEADA No 13.50%

ENDOCRINE THIOLA Yes 11.40%

ONCOLOGY -

ORAL ERLOTINIB Yes 33.00%

ENDOCRINE TOLVAPTAN Yes 33.00%

ONCOLOGY -

ORAL ETOPOSIDE No 33.00%

ENDOCRINE TRIENTINE No 84.50%

ONCOLOGY -

ORAL EVEROLIMUS No 45.40%

ENDOCRINE XERMELO Yes 13.00%

ONCOLOGY -

ORAL EXKIVITY Yes 13.00%

ENDOCRINE XURIDEN Yes 12.50%

ONCOLOGY -

ORAL FARYDAK Yes 11.40%

ENZYME

DEFICIENCY CHOLBAM Yes 4.20%

ONCOLOGY -

ORAL FOTIVDA Yes 13.20%

Page | 14

ENZYME

DEFICIENCY CYSTAGON Yes 10.90%

ONCOLOGY -

ORAL GAVRETO Yes 12.50%

ENZYME

DEFICIENCY GALAFOLD Yes 14.00%

ONCOLOGY -

ORAL GILOTRIF Yes 7.30%

ENZYME

DEFICIENCY MIGLUSTAT No 33.00%

ONCOLOGY -

ORAL GLEEVEC No 15.40%

ENZYME

DEFICIENCY NITISINONE Yes 33.00%

ONCOLOGY -

ORAL GLEOSTINE No 15.40%

ENZYME

DEFICIENCY ORFADIN Yes 2.20%

ONCOLOGY -

ORAL HYCAMTIN No 14.80%

ENZYME

DEFICIENCY PALYNZIQ Yes 11.40%

ONCOLOGY -

ORAL IBRANCE Yes 14.00%

ENZYME

DEFICIENCY STRENSIQ Yes 11.30%

ONCOLOGY -

ORAL ICLUSIG Yes 12.70%

ENZYME

DEFICIENCY SUCRAID Yes 12.20%

ONCOLOGY -

ORAL IDHIFA No 14.50%

ENZYME

DEFICIENCY TEGSEDI Yes 7.30%

ONCOLOGY -

ORAL

IMATINIB

MESYLATE No 92.30%

ENZYME

DEFICIENCY ZAVESCA Yes 7.30%

ONCOLOGY -

ORAL IMBRUVICA Yes 14.00%

GAUCHERS

DISEASE CERDELGA Yes 13.50%

ONCOLOGY -

ORAL INLYTA Yes 13.60%

GENETIC

DISORDER DOJOLVI Yes 15.00%

ONCOLOGY -

ORAL INQOVI Yes 10.40%

GENETIC

DISORDER ZOKINVY Yes 13.50%

ONCOLOGY -

ORAL INREBIC Yes 12.50%

GROWTH

HORMONE

DEFICIENCY GENOTROPIN No 14.10%

ONCOLOGY -

ORAL IRESSA Yes 14.50%

GROWTH

HORMONE

DEFICIENCY HUMATROPE No 14.70%

ONCOLOGY -

ORAL JAKAFI Yes 12.50%

GROWTH

HORMONE

DEFICIENCY INCRELEX Yes 13.50%

ONCOLOGY -

ORAL KISQALI Yes 14.50%

GROWTH

HORMONE

DEFICIENCY NORDITROPIN No 16.00%

ONCOLOGY -

ORAL

KISQALI

FEMARA Yes 15.00%

GROWTH

HORMONE

DEFICIENCY NUTROPIN AQ No 14.20%

ONCOLOGY -

ORAL KOSELUGO Yes 13.70%

GROWTH

HORMONE

DEFICIENCY OMNITROPE No 14.50%

ONCOLOGY -

ORAL LAPATINIB Yes 33.00%

GROWTH

HORMONE

DEFICIENCY SAIZEN No 17.50%

ONCOLOGY -

ORAL LENALIDOMIDE Yes 33.00%

GROWTH

HORMONE

DEFICIENCY SEROSTIM Yes 13.50%

ONCOLOGY -

ORAL LENVIMA Yes 14.50%

GROWTH

HORMONE

DEFICIENCY SKYTROFA No 11.40%

ONCOLOGY -

ORAL LONSURF Yes 12.50%

GROWTH

HORMONE

DEFICIENCY ZOMACTON No 14.70%

ONCOLOGY -

ORAL LORBRENA Yes 11.40%

GROWTH

HORMONE

DEFICIENCY ZORBTIVE Yes 13.00%

ONCOLOGY -

ORAL LUMAKRAS Yes 12.50%

HEMATOLOGIC BERINERT Yes 12.50%

ONCOLOGY -

ORAL LYNPARZA Yes 12.20%

HEMATOLOGIC CABLIVI Yes 13.50%

ONCOLOGY -

ORAL MATULANE Yes 13.00%

HEMATOLOGIC CINRYZE Yes 14.50%

ONCOLOGY -

ORAL MEKINIST Yes 11.40%

HEMATOLOGIC DOPTELET Yes 13.50%

ORAL MEKTOVI Yes 14.00%

Page | 15

HEMATOLOGIC FIRAZYR Yes 14.30%

ONCOLOGY -

ORAL MELPHALAN No 33.00%

HEMATOLOGIC HAEGARDA Yes 12.50%

ONCOLOGY -

ORAL MESNEX No 14.00%

HEMATOLOGIC ICATIBANT Yes 33.00%

ONCOLOGY -

ORAL NERLYNX Yes 14.30%

HEMATOLOGIC MOZOBIL No 13.50%

ONCOLOGY -

ORAL NEXAVAR Yes 12.50%

HEMATOLOGIC MULPLETA No 13.50%

ONCOLOGY -

ORAL NILANDRON No 15.00%

HEMATOLOGIC OXBRYTA Yes 11.90%

ONCOLOGY -

ORAL NILUTAMIDE No 40.40%

HEMATOLOGIC PROMACTA Yes 13.50%

ONCOLOGY -

ORAL NINLARO No 13.50%

HEMATOLOGIC REZUROCK Yes 13.20%

ONCOLOGY -

ORAL NUBEQA Yes 13.50%

HEMATOLOGIC RUCONEST Yes 13.20%

ONCOLOGY -

ORAL ODOMZO No 13.80%

HEMATOLOGIC SAJAZIR Yes 22.80%

ONCOLOGY -

ORAL ONUREG No 11.90%

HEMATOLOGIC TAKHZYRO Yes 13.50%

ONCOLOGY -

ORAL ORGOVYX Yes 14.30%

HEMATOLOGIC TAVALISSE Yes 13.50%

ONCOLOGY -

ORAL PEMAZYRE Yes 14.00%

HEMOPHILIA -

INFUSED ADVATE No 43.20%

ONCOLOGY -

ORAL PIQRAY No 11.90%

HEMOPHILIA -

INFUSED ADYNOVATE No 34.10%

ONCOLOGY -

ORAL POMALYST Yes 13.00%

HEMOPHILIA -

INFUSED AFSTYLA No 34.00%

ONCOLOGY -

ORAL PURIXAN No 12.50%

HEMOPHILIA -

INFUSED

ALPHANATE/V

ON

WILLEBRAND No 42.00%

ONCOLOGY -

ORAL QINLOCK Yes 14.50%

HEMOPHILIA -

INFUSED ALPHANINE SD No 49.30%

ONCOLOGY -

ORAL RETEVMO Yes 12.50%

HEMOPHILIA -

INFUSED ALPROLIX No 13.50%

ONCOLOGY -

ORAL REVLIMID Yes 14.80%

HEMOPHILIA -

INFUSED BENEFIX No 14.50%

ONCOLOGY -

ORAL ROZLYTREK No 15.40%

HEMOPHILIA -

INFUSED COAGADEX Yes 30.00%

ONCOLOGY -

ORAL RUBRACA Yes 14.50%

HEMOPHILIA -

INFUSED CORIFACT No 27.90%

ONCOLOGY -

ORAL RYDAPT No 15.40%

HEMOPHILIA -

INFUSED ELOCTATE No 27.90%

ONCOLOGY -

ORAL SCEMBLIX No 11.40%

HEMOPHILIA -

INFUSED ESPEROCT No 22.80%

ONCOLOGY -

ORAL SPRYCEL No 15.40%

HEMOPHILIA -

INFUSED FEIBA No 40.20%

ONCOLOGY -

ORAL STIVARGA Yes 11.90%

HEMOPHILIA -

INFUSED HEMOFIL M No 44.40%

ONCOLOGY -

ORAL SUNITINIB Yes 33.00%

HEMOPHILIA -

INFUSED HUMATE-P No 37.10%

ONCOLOGY -

ORAL SUTENT Yes 14.80%

HEMOPHILIA -

INFUSED IDELVION No 13.50%

ONCOLOGY -

ORAL TABLOID No 15.40%

HEMOPHILIA -

INFUSED IXINITY No 13.50%

ONCOLOGY -

ORAL TABRECTA No 12.50%

HEMOPHILIA -

INFUSED JIVI No 22.80%

ONCOLOGY -

ORAL TAFINLAR Yes 13.50%

HEMOPHILIA -

INFUSED KOATE No 42.30%

ONCOLOGY -

ORAL TAGRISSO Yes 13.50%

HEMOPHILIA -

INFUSED KOATE-DVI No 42.30%

ONCOLOGY -

ORAL TALZENNA Yes 13.50%

HEMOPHILIA -

INFUSED KOGENATE FS No 47.30%

ONCOLOGY -

ORAL TARCEVA Yes 15.30%

HEMOPHILIA -

INFUSED KOVALTRY No 45.70%

ORAL TARGRETIN No 14.00%

Page | 16

HEMOPHILIA -

INFUSED MONONINE No 31.40%

ONCOLOGY -

ORAL TASIGNA Yes 13.50%

HEMOPHILIA -

INFUSED NOVOEIGHT No 44.30%

ONCOLOGY -

ORAL TAZVERIK Yes 13.70%

HEMOPHILIA -

INFUSED NOVOSEVEN RT No 38.30%

ONCOLOGY -

ORAL TEMODAR No 14.80%

HEMOPHILIA -

INFUSED NUWIQ No 48.20%

ONCOLOGY -

ORAL TEMOZOLOMIDE No 59.20%

HEMOPHILIA -

INFUSED PROFILNINE No 30.00%

ONCOLOGY -

ORAL TEPMETKO Yes 12.50%

HEMOPHILIA -

INFUSED REBINYN No 17.60%

ONCOLOGY -

ORAL THALOMID Yes 14.80%

HEMOPHILIA -

INFUSED RECOMBINATE No 41.30%

ONCOLOGY -

ORAL TIBSOVO Yes 13.50%

HEMOPHILIA -

INFUSED RIXUBIS No 13.70%

ONCOLOGY -

ORAL TRETINOIN No 84.50%

HEMOPHILIA -

INFUSED SEVENFACT No 22.80%

ONCOLOGY -

ORAL TRUSELTIQ Yes 13.00%

HEMOPHILIA -

INFUSED TRETTEN Yes 14.40%

ONCOLOGY -

ORAL TUKYSA Yes 13.70%

HEMOPHILIA -

INFUSED VONVENDI Yes 12.50%

ONCOLOGY -

ORAL TURALIO Yes 14.00%

HEMOPHILIA -

INFUSED WILATE No 42.30%

ONCOLOGY -

ORAL TYKERB Yes 14.80%

HEMOPHILIA -

INFUSED XYNTHA No 38.40%

ONCOLOGY -

ORAL UKONIQ Yes 12.50%

HEMOPHILIA -

INJECTABLE HEMLIBRA Yes 12.50%

ONCOLOGY -

ORAL VENCLEXTA Yes 12.50%

HEPATITIS B

ADEFOVIR

DIPIVOXIL No 33.00%

ONCOLOGY -

ORAL VERZENIO Yes 15.20%

HEPATITIS B BARACLUDE No 13.80%

ONCOLOGY -

ORAL VITRAKVI Yes 14.50%

HEPATITIS B EMPAVELI Yes 13.50%

ONCOLOGY -

ORAL VIZIMPRO Yes 8.30%

HEPATITIS B ENTECAVIR No 83.50%

ONCOLOGY -

ORAL VOTRIENT Yes 13.50%

HEPATITIS B EPIVIR HBV No 14.30%

ONCOLOGY -

ORAL WELIREG Yes 13.20%

HEPATITIS B HEPSERA No 13.70%

ONCOLOGY -

ORAL XALKORI Yes 11.90%

HEPATITIS B

LAMIVUDINE

HBV No 33.00%

ONCOLOGY -

ORAL XELODA No 15.40%

HEPATITIS B VEMLIDY No 13.30%

ONCOLOGY -

ORAL XOSPATA Yes 14.50%

HEPATITIS C EPCLUSA No 14.00%

ONCOLOGY -

ORAL XPOVIO Yes 14.30%

HEPATITIS C HARVONI No 15.00%

ONCOLOGY -

ORAL XTANDI Yes 13.50%

HEPATITIS C

LEDIPASVIR/SO

FOSBUVIR No 15.00%

ONCOLOGY -

ORAL YONSA No 15.40%

HEPATITIS C MAVYRET No 14.00%

ONCOLOGY -

ORAL ZEJULA Yes 13.70%

HEPATITIS C PEGASYS No 16.50%

ONCOLOGY -

ORAL ZELBORAF Yes 13.00%

HEPATITIS C PEGINTRON No 17.50%

ONCOLOGY -

ORAL ZOLINZA No 14.80%

HEPATITIS C

SOFOSBUVIR/V

ELPATASVIR No 14.00%

ONCOLOGY -

ORAL ZYDELIG Yes 14.50%

HEPATITIS C SOVALDI No 14.00%

ONCOLOGY -

ORAL ZYKADIA Yes 13.00%

HEPATITIS C VIEKIRA PAK No 13.50%

ONCOLOGY -

ORAL ZYTIGA No 13.50%

HEPATITIS C VOSEVI No 14.00%

ONCOLOGY -

TOPICAL TARGRETIN No 14.00%

HEPATITIS C ZEPATIER No 13.90%

ONCOLOGY -

TOPICAL VALCHLOR Yes 9.90%

HEPATOLOGY BYLVAY Yes 11.40% OPHTHALMIC OXERVATE Yes 12.50%

Page | 17

HEREDITARY

ANGIODEMA ORLADEYO Yes 13.00% OSTEOPOROSIS FORTEO No 13.90%

IMMUNE

MODULATOR ACTIMMUNE Yes 14.30% OSTEOPOROSIS TERIPARATIDE No 13.50%

IMMUNE

MODULATOR ARCALYST Yes 15.00% OSTEOPOROSIS TYMLOS No 13.30%

IMMUNOLOGICAL

AGENTS LUPKYNIS Yes 14.30%

PARKINSONS

DISEASE APOKYN Yes 11.50%

IMMUNOLOGICAL

AGENTS PALFORZIA Yes 9.40%

PARKINSONS

DISEASE INBRIJA Yes 12.50%

IMMUNOLOGICAL

AGENTS TAVNEOS Yes 14.10%

PARKINSONS

DISEASE KYNMOBI Yes 9.40%

INFERTILITY CETROTIDE No 17.20%

PULMONARY

DISEASE ESBRIET Yes 13.50%

INFERTILITY

CHORIONIC

GONADOTROPI

N No 69.60%

PULMONARY

DISEASE OFEV Yes 12.50%

INFERTILITY FOLLISTIM AQ No 24.30%

PULMONARY

HYPERTENSION ADCIRCA No 13.50%

INFERTILITY

GANIRELIX

ACETATE No 16.60%

PULMONARY

HYPERTENSION ADEMPAS Yes 13.50%

INFERTILITY GONAL-F No 22.90%

PULMONARY

HYPERTENSION ALYQ No 58.80%

INFERTILITY GONAL-F RFF No 22.90%

PULMONARY

HYPERTENSION AMBRISENTAN Yes 58.80%

INFERTILITY MENOPUR No 16.80%

PULMONARY

HYPERTENSION BOSENTAN Yes 33.00%

INFERTILITY NOVAREL No 33.00%

PULMONARY

HYPERTENSION LETAIRIS Yes 12.70%

INFERTILITY OVIDREL No 17.20%

PULMONARY

HYPERTENSION OPSUMIT Yes 13.70%

INFERTILITY PREGNYL No 33.00%

PULMONARY

HYPERTENSION ORENITRAM Yes 13.50%

INFLAMMATORY

CONDITIONS ACTEMRA No 14.20%

PULMONARY

HYPERTENSION REVATIO No 13.30%

INFLAMMATORY

CONDITIONS ADBRY Yes 10.40%

PULMONARY

HYPERTENSION SILDENAFIL No 95.70%

INFLAMMATORY

CONDITIONS CIBINQO No 13.50%

PULMONARY

HYPERTENSION TADALAFIL No 33.00%

INFLAMMATORY

CONDITIONS CIMZIA No 15.50%

PULMONARY

HYPERTENSION TRACLEER Yes 13.50%

INFLAMMATORY

CONDITIONS COSENTYX No 13.50%

PULMONARY

HYPERTENSION TYVASO Yes 13.00%

INFLAMMATORY

CONDITIONS DUPIXENT No 14.10%

PULMONARY

HYPERTENSION UPTRAVI Yes 14.80%

INFLAMMATORY

CONDITIONS EMFLAZA Yes 10.90%

PULMONARY

HYPERTENSION VENTAVIS* Yes 13.00%

INFLAMMATORY

CONDITIONS ENBREL No 14.50%

*Includes Nebulizer

6/2022