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Pharmacy Services Manual 2010

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Prescription claims must be submitted through the TelePAID® System only for the Member for whom the prescription is written by the Prescriber. Any requests for an interpretation of this Pharmacy Services Manual (PSM) should be submitted in writing. Inquiries regarding this PSM, claims processing, claims adjustments, nonpayment of claims, or professional questions should be directed to: MemberHealth, LLC Pharmacy Network Operations 29100 Aurora Road Solon, Ohio 44139 or [email protected] or MHRx Pharmacy Services Help Desk at 866-684-5395

MHRx's Pharmacy Services Help Desk Available 7 days a week, 24 hours a day, including holidays. To access the PSM online: www.mhrx.com

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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TABLE OF CONTENTS 1.0 General Information.....................................................................................5-6 1.1 MHRx Standards of Practice ..............................................................................7 1.2 Company Pharmacy and/or Provider Standards of Practice ...........................................7 1.3 Overview of the MHRx Programs........................................................................7-8 1.4 Identification of Members .................................................................................8 1.5 Examples of Prescription Drug ID Cards for plans administered/supported by MHRx...............9 2.0 Claims Submission Protocols ....................................................................................................10 2.1 TelePAID® Claims System .........................................................................................................11 NDC Number and Package Size, Unbreakable packages, Days' Supply .................. ....... 11 Required Identification Numbers ................................................................. ..... 12 Coordination of Benefits/Split Billing/Secondary Claims........................................ .12 E - Prescribing ...................................................................................................................13 Quantity Dispensed ..................................................................................14 Sales Tax .............................................................................................. 18 Compounded Prescriptions ....................................................................... 18 Procedures for Submitting Compounded Prescription Claims ...............................................18 Claims Adjustments.............................................................................................................19 2.2 Co-payment/Coinsurance ..........................................................................................................19 2.3 Prior Authorization ............................................................................................................. 19-20 3.0 Managing Clinical Messages and Opportunities .....................................................................21 3.1 Clinical Programs .....................................................................................................................22 Clinical Messages ..............................................................................................................22 Drug Utilization Review ("DUR")........................................................................................22 Temporary Coverage Policy ........................................................................................ 22-23 3.2 DUR Specification Codes ...........................................................................................................23 General DUR Specification Codes .....................................................................................23 DUR Reason for Service Codes and Descriptions ......................................................... 23-25 DUR Professional Service Codes and Descriptions ....................................................... 25-26 DUR Result of Service Codes and Descriptions ..................................................................26 3.3 Submission Clarification Codes .................................................................................................27 3.4 TelePAID® Submission Reject Codes ........................................................................................27 4.0 Prescrption Substitution Standards ................................................................................................ 28 4.1 Generic Drug Standards ............................................................................................................29 4.2 Dispense As Written ("DAW") Codes ................................................................................. 29-30 4.3 Formulary Drug Standards .................................................................................................. 30-31 5.0 Professional Audits ................................................................................................................... 32 6.0 Miscellaneous Provider Issues .................................................................................................. 33 6.1 Miscellaneous Provider Issues ................................................................................................. 34 6.2 Advertising .............................................................................................................................. 34 6.3 Change of Ownership ..................................................................................................................... 34 6.4 Best Available Evidence (BAE) and Low Income Subsidy (LIS) Policy ................................35-36 6.5 Frequently Asked Questions ................................................................................................. 36-37 6.6 Glossary ................................................................................................................................... 38 6.7 MHRx Claims Cycle and Payments ..................................................................................... 38-40 7.0 Additional Compliance Requirements ........................................................................................ 41 7.1 Fraud, Waste, and Abuse Training .................................................................................................. 42 7.2 Formulary Change Notification ....................................................................................................... 43 7.3 CMS Provider Marketing Guidelines for Pharmacies and Pharmacists................................... 43-44 7.4 Medicare Prescription Drug Coverage and Your Rights ................................................................ 45 © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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SECTION 1.0 GENERAL INFORMATION

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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GENERAL INFORMATION MemberHealth publishes this Pharmacy Services Manual (MHPSM) to assist Providers in correctly submitting claims for persons eligible under a MemberHealth administered benefit plan. The majority of MemberHealth administered lives are under a Medicare Part D plan and as such, this manual includes additional information specific to Part D that is aimed at helping pharmacies serve their Part D members under our plans in a safe and expeditious manner. This version of the MHPSM supersedes and replaces all prior versions of the MHPSM. To the extent this version of the MHPSM is inconsistent with any network schedules, the terms listed throughout the MHPSM shall govern. The information contained herein is confidential and proprietary to MemberHealth. The MHPSM is incorporated into your existing MemberHealth pharmacy agreement. Participating pharmacies are expected to follow the policies and instructions within the MHPSM as if it is part of their binding agreement with MemberHealth (Agreement). Any noncompliance with the MHPSM constitutes breach of the Participating Pharmacy agreement. Participating pharmacies should obtain a copy of the MHPSM via the web-delivery resource available and update their copy with regularity, no less than once per year (suggested to be at the start of the calendar year). Participating pharmacies should become familiar with the policies and guidance in the MHPSM and review subsequent copies for changes that modify a pharmacy's responsibilities under this document. Any participating pharmacy that provides covered services to a person eligible under a MemberHealth administered benefit plan is affirming the terms and provisions contained in the MHPSM at the time covered services are provided. Persons covered under MemberHealth administered plans may have many different designs as they pertain to days' supply, copayment / co-insurance, drug coverage, step therapy requirements, and drug utilization review edits. Accurate information as to a person's eligible benefit pertaining to a submitted claim will be returned to the participating pharmacy via our claims processing vendor's system, Medco's TelePAID system. If you have questions beyond what is addressed in the MHPSM, please contact MemberHealth Network Operations at: MemberHealth, LLC Pharmacy Network Operations 29100 Aurora Road Solon, Ohio 44139

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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1.1 MEMBERHEALTH STANDARDS OF PRACTICE · MemberHealth, LLC ("MHRx") reimburses Company Pharmacies and/or Providers according to the claims cycle schedule included within this PSM. · National Drug Code ("NDC") and Average Wholesale Price ("AWP") files are updated on a daily basis. · MHRx will use the TelePAID® claims system for all claims adjudication. The TelePAID® System will be available 99.5% of the time, excluding routine scheduled maintenance. · The TelePAID® claims will be adjudicated, on average, within 3 seconds. 1.2 COMPANY PHARMACY AND/OR PROVIDER STANDARDS OF PRACTICE · When a multisource brand drug product is dispensed, process the claim with the appropriate Dispense as Written ("DAW") Code according to the DAW Code Standards Section of this PSM. · Reinforce the use of generic and preferred brand products with Members and prescribers. · Display all Drug Utilization Review ("DUR") alerts to the dispensing pharmacist. · Inform Members as to the proper storage, dosing, side effects, potential interactions, and use of the medication dispensed within professional practice guidelines. · Submit claims via the TelePAID® System only for patient for whom the prescription was written by the Prescriber. · Reverse claims for any drug product returned to stock within 14 days of the date the claim was originally billed. · Company Pharmacy and/or Provider must not, under any circumstances, undermine U&C or compound pricing as a component of the compensation contemplated in this PSM or the Agreement in any way, including but not limited to: (1) owning, operating, or affiliating with a nonparticipating pharmacy; or, (2) separating cash and third-party prescription business. Company Pharmacy and/or Provider will not participate in the MHRx Participating Pharmacy Network if MHRx determines in its sole discretion that Company Pharmacy and/or Provider has taken actions to undermine U&C or compound pricing. · Company Pharmacy and/or Provider will inform MHRx within 14 days of the removal of prescription records from Company Pharmacy and/or Provider's custody by an authorized Federal, State, or local agency. Upon request, a receipt provided by the agency removing the records and/or the name and phone number of the agent removing the records must be furnished to MHRx's Pharmacy Audit Department. · Substitute generic drug products for multisource brand drug products according to prevailing pharmacy laws and regulations. · Basis of calculations for ingredient cost, the dispensing fee, sales tax, and co-payment/coinsurance will be returned to Provider on TelePAID® System response. · Submit accurate National Provider Identification (NPI), Drug Enforcement Administration (DEA) number, State Medical Board License Number, or other Prescriber identifier on all claims in the correct NCPDP field. 1.3 OVERVIEW OF MEMBERHEALTH PROGRAMS MHRx or the Part D Plan Sponsor provides each Member with a prescription ID card that contains the Part D Plan's logo and MHRx's mark or some other indication that the program is administered by MHRx. Company © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Pharmacy and/or Provider is required to honor this card regardless of the state in which the member lives. The cards contain information, such as the Member's identification number and group number that enables the claim to be processed through the TelePAID® System. MHRx services many plans. Each has its own guidelines as to such things as days' supply, ingredient cost pricing, co-payment/coinsurance, drug coverage, and informational drug utilization messaging. Therefore, rely on the TelePAID® System to receive accurate information regarding the specific patient, group, prescription drug, co-payment/coinsurance, and pricing pertaining to the claim submitted. Answers to most questions about MHRx can be obtained by reading this PSM. For questions not covered in this PSM, please contact: The Pharmacy Services Help Desk at 866-684-5395 or write to: MemberHealth, LLC Pharmacy Network Operations 29100 Aurora Road Solon, Ohio 44139 1.4 IDENTIFICATION OF MEMBERS MHRx or Part D Plan Sponsors may furnish Members with prescription drug ID card to be presented at Company Pharmacy and/or Provider or may implement alternative eligibility verification methods. Company Pharmacy and/or Provider must submit prescription drug claims only for the Member for whom the prescription is written by the Prescriber. Company Pharmacy and/or Provider will not be paid for Covered Prescription Services provided to persons whose eligibility to participate in a MHRx program has not been verified and communicated to Company Pharmacy and/or Provider by the TelePAID® System or other applicable eligibility verification methods used by MHRx, or if the claim was submitted for an Member other than the person for whom the prescription was written by the Prescriber. Signature logs must conform on an ongoing basis to the requirements set forth under the Maintenance of Records; Audits section of the Agreement for Third-Party Signature Claim Logs. Company Pharmacy and/or Provider will obtain the signature of the Member or his/her authorized agent in Company Pharmacy and/or Provider's Third-Party Signature Claim Log Book confirming receipt of the prescription and the required certification statement for all claims submitted through the TelePAID® System. Company Pharmacy and/or Provider will not be entitled to payment for any claims not supported by a logbook signature. Member information necessary to file a claim is contained in the Agreement under Exhibit C (Prescription Information/Payer Sheet) ("MHRx Payer Sheet")

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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1.5 EXAMPLES OF MHRx PRESCRIPTION DRUG ID CARDS

Eligibility of the individual patient for whom the prescription is prescribed is confirmed via the TelePAID® System. Cards are valid for only the cardholder whose name is embossed on the prescription drug ID card.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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SECTION 2.0 C L A I M S S U B M I S S I O N PROTOCOLS

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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2.1 TelePAID® C L A I M S S Y S T E M The TelePAID® System sets forth pricing, eligibility, and other information that governs participation in the network applicable to each Part D Plan Sponsor and Member. The TelePAID® System also provides information necessary to effectively implement MHRx's clinical and benefit management initiatives such as drug utilization review, prior authorization, and formulary management programs on behalf of Part D Plan Sponsors. Company Pharmacy and/or Provider will submit all claims through the TelePAID® System and will comply with all information communicated via the TelePAID® System or otherwise by MHRx. All claims must contain complete and accurate information for each prescription dispensed. Claims must be submitted only for the Member for whom the prescription is written by the Prescriber. Company Pharmacy and/or Provider will transmit claims to TelePAID® with all required fields as defined by MHRx using the most current NCPDP standard defined by the MHRx Payer Sheet. The most current Payer Sheet can be obtained through any of the following channels or as part of the Agreement: · · · · [email protected] www.mhrx.com Pharmacy Services Help Desk: 866-684-5395 Write to: MemberHealth, LLC 29100 Aurora Road Solon, Ohio 44139

All authorized refills of any prescription must bear the original prescription number. An on-site registered and licensed pharmacist experienced in third-party procedures will supervise the claims submitted by Company Pharmacy and/or Provider. All claims submitted by Company Pharmacy and/or Provider will be in accordance with the metric decimal quantity guidelines as established by NCPDP from time to time. Company Pharmacy and/or Provider will submit all TelePAID® System claims simultaneously with dispensing unless unusual circumstances require otherwise, in which event Company Pharmacy and/or Provider will submit TelePAID® System claims within 30 days of the date of service.

NDC Number and Package Size NDC number must appear on submitted claims as defined in the current MHRx Payer Sheet. Company Pharmacy and/or Provider must submit the complete NDC number of the package size dispensed. Unbreakable Packages Drugs labeled to be dispensed only in the original container or package must be dispensed in the original packaging for all Universal American plans covering such drugs products, as directed. All other packages, including nitroglycerin patches, are considered "breakable" and as such must be dispensed in the quantity prescribed. Days' Supply A Provider must submit an accurate days' supply on the submitted claim based on the actual metric quantity of product dispensed and/or the product manufacturer's stated content (for example the number of inhalations per canister), and the Prescriber's dosage direction. Provider must clarify ambiguous © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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dosage direction prior to dispensing or utilize peer reviewed dispensing practice guidelines. For example, a prescription order for albuterol inhaler with instructions of "as directed" should not be assigned an arbitrary days' supply. The actual days' supply should be determined based on the manufacturers' labeled quantity, e.g., 200 metered doses per unit, divided by the number of doses prescribed. Prescriber must clarify days' supply by talking to the Eligible Person and/or Prescriber and document on the prescription.

Required Identification Numbers · National Provider Identifier

National Provider Identifier (NPI) is the required pharmacy and Prescriber identifier by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) replacing legacy identifiers (e.g., CPDP ® number, DEA) on all claims submitted through the TelePAID System. The NPI is a unique 10-digit identifier assigned to healthcare providers, such as Prescribers and pharmacies, to use when submitting a HIPAA standard transaction. · Identifiers that Providers Must Put on Claims Submitted

Provider is required to submit accurate information identifying the Prescriber for each claim submitted. A valid NPI number ("01"), DEA number ("12"), or state license number ("08") is to be submitted with all claims in the Prescriber ID field. The Prescriber Identifier should be the prescribing individual's NPI number. If NPI is not available, state license or DEA number will be accepted, as permitted. Provider will not submit Provider's DEA or NPI number in this field. Prescriptions dispensed to Eligible Persons must be from the Provider location documented in Medco's Agreement with Provider. The NPI number (qualifier code "01"), NCPDP number (qualifier code "07") and Medco Pharmacy account number (Pharmacy Identification number "99") under which the claim was submitted to and adjudicated by Medco must identify the location where the pharmacist supervised dispensing of the prescription.

Coordination of Benefits/Split Billing/Secondary Claims MHRx supports electronic coordination of benefits ("COB"), split billing, and secondary claims in accordance with the standards of NCPDP v5.1. The COB segment is required when submitting secondary claims. COB values 1 through 7 are supported and will drive claim if secondary adjudication applies. Claims denied by primary carrier should be submitted with the NCPDP v5.1 reject code identified on the COB segment. Include "other coverage" code when reversing a claim, because MHRx can offer both primary and secondary coverage even when same cardholder ID has both benefits. If Company Pharmacy and/or Provider receives a reject message indicating group does not accept secondary coverage, notify cardholder. MHRx does not accept Universal Claim Form ("UCF") hard-copy claims for purpose of billing secondary coverage from Company Pharmacy and/or Provider. Company Pharmacy and/or Provider can submit a COB claim electronically through the TelePAID® System up to 90 days from date of service.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Effective January 1, 2010, the Prescription Origin Code (field 419-DJ in NCPDP version 5.1) is a mandatory field on submitted claims and must be populated in order for a Medicare Part D claim to be processed based on CMS directive.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Quantity Dispensed The Quantity Dispensed transmitted via the TelePAID System for all Medco claims must reflect the exact quantity dispensed, including metric decimal amounts. Pharmacy software must conform to the then-current NCPDP Standard for the "Quantity Dispensed" field.

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There are three standard billing units used to describe drug products. These billing units are "EA" (eaches), "ML" (milliliters), and "GM" (grams). Products that are measured in units and not measured by weight or volume are billed as the number of "eaches" dispensed. · Some representative "eaches" dosage forms are tablets, capsules, transdermal patches, nonfilled syringes, and reconstitutable injectable vials. These forms should be expressed as the number of units dispensed in the Quantity Dispensed field. 30 tablets dispensed Quantity Dispensed field = 30 30 insulin syringes dispensed Quantity Dispensed field = 30

Example:

Example:

Products such as solutions and injectable liquids that are measured by liquid volume are billed as the number of "milliliters" dispensed. · Examples of representative dosage forms measured by liquid volume can include liquids, suspensions, solutions, IV solutions, irrigations, nasal sprays, oral inhalers, reconstituted noninjectable liquid dosage forms, etc., and should be expressed as the exact number of milliliters dispensed including metric decimal quantity amounts in the Quantity Dispensed field. Insulin 10 mL 2 vials dispensed (10x2) Quantity Dispensed field = 20 Ipratropium Bromide 0.02%, 2.5 mL/nebule Report quantity dispensed in exact milliliters multiplied by the number of nebules dispensed. 25 nebules dispensed (2.5x25) Quantity Dispensed field = 62.5

Example:

Example:

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Exception: Imitrex Nasal Spray 20 mg Representative NDC 00173052300 One container dispensed Report quantity of containers dispensed in the Quantity Dispensed field. Quantity Dispensed field = 1

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Oral antibiotic suspensions, eye drops, and other noninjectable dosage forms that require reconstitution prior to dispensing and are labeled by volume should be expressed in milliliters. These products should be expressed with the exact number of milliliters, including the metric decimal quantity amounts, in the Quantity Dispensed field. Amoxicillin Suspension 150 mL (150x1) One 150-mL bottle dispensed Quantity Dispensed field = 150

Example:

Products that are measured by weight are billed as the number of "grams" dispensed and are labeled with grams on the product. · Examples of representative products that are measured by weight can include ointments, creams, balms, bulk powders, inhalers, etc., and should be expressed as the exact number of grams dispensed including metric decimal quantity amounts in the Quantity Dispensed field. Asmanex Twisthaler NDC 00085134103 Total grams = 0.24 grams (30 inhalations) Quantity Dispensed field = 0.24 Bethamethasone Valerate Cream 15 gm One 15-gm tube dispensed Quantity Dispensed field = 15 Bacitracin Ophthalmic Ointment 3.5 g One 3.5-gm tube dispensed Quantity Dispensed field = 3.5 Androgel Gel Packet Representative NDC 54868481000 Dispensed 30 packets containing 5 gm each (30 packets x 5 gm) Total grams = 150 Quantity Dispensed field = 150

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Example:

Example:

Example:

Example:

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Exception: Pulmicort Flexhaler 180 mcg Representative NDC 00186091612 One container dispensed Quantity Dispensed field = 1

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Additional Clarification Partially Filled Containers: If the product is in a partially filled container, the quantity dispensed is the amount of fill volume containing the actual drug and should be expressed in milliliters. Example: Dextrose 5% 250 mL in a 500-mL bottle Quantity Dispensed field = 250

Packets: Powder packet products such as Questran should be expressed by number of packets dispensed. Example: Questran Representative NDC 49884093665 60 packets dispensed Quantity Dispensed field = 60

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Disposable Enemas: If enemas are labeled volumetrically, the quantity dispensed should be expressed in milliliters. Example: Rowasa Representative NDC 68220002207 7 enemas dispensed 60 mL per enema (60x7) Quantity Dispensed field = 420 If enema is not labeled volumetrically, then the quantity dispensed would be expressed as the number of units dispensed.

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© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Combination Packages: Drug products that are packaged with more than one drug in different dosage forms should be expressed as units of 1. Example: Clindareach Representative NDC 65880050302 Package contains: pledgets, appliqués, cleansing pads, and applicator. Quantity Dispensed field = 1 Duac CS Convenience Kit Representative NDC 00145236701 Package contains 2 different products Quantity Dispensed field = 1

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Example:

Convenience Packets, Therapy Packs, and Prepackages: Convenience packets, therapy packs, and prepackages must be billed as the number of individual tablets or capsules (units) dispensed, not the number of boxes or packages. Example: Chantix Representative NDC 00069047197 Package size = 53 tablets Quantity Dispensed field = 53

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© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Sales Tax Medco supports all state sales tax fields in accordance with the most current NCPDP electronic claims standard (currently version 5.1). The amount of any allowable taxes will be specifically identified on each claim submitted by Provider as a condition of payment by Medco. For those states that require sales tax on prescriptions, Provider should identify the percentage sales tax rate and tax basis amount used to determine the sales tax amount.

Compounded Prescriptions A compounded prescription is one that meets the following criteria: The compound consists of two or more solid, semisolid, or liquid ingredients, one of which is a Federal Legend Drug that is weighed, measured, prepared, or mixed according to the prescription order. Reconstitution of an oral antibiotic or any other similar product is not considered a compounded prescription. The addition of flavorings to a commercial product is also not considered a compounded prescription. The pharmacist is responsible for compounding preparations with approved ingredients of acceptable strength, quality, and purity, with appropriate packaging and labeling in accordance with good compounding practices, official standards, and relevant scientific information. The Company Pharmacy and/or Provider is responsible for documenting all compounded prescriptions, including but not limited to the drug's name, NDC of the package size used, manufacturer name where an NDC is not available and metric quantity of each component used to prepare the compounded prescription. Procedures for Submitting Compounded Prescription Claims Compounded Prescriptions are required to be submitted via the TelePAID ® System in accordance with the following: 1. Submitthe "Compound Flag" to positive in accordance with the Company Pharmacy and/or Provider Software and NCPDP standards as defined by MHRx's most current Payer Sheet. 2. Submit the NDC number for the highest-priced Federal Legend Drug contained in the compound or the NDC that most accurately reflects the cost of the compound and package size used. 3. Submit the quantity dispensed as the total metric quantity of the finished product. 4. Submit the Company Pharmacy and/or Provider's submitted ingredient cost for the compounded prescription and the Company Pharmacy and/or Provider's U&C price. 5. Submit Eligible Person andgroup information as you would for any other MHRx claim. 6. Collect from the Eligible Persononly the applicable co-payment/ coinsurance as indicated through the TelePAID ® System. * Charges for ancillary supplies, flavoring, equipment, equipment depreciation, and/or labor are not eligible for reimbursement.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Claims Adjustments Company Pharmacy and/or Provider may request an adjustment to any claim for which Company Pharmacy and/or Provider's records indicate that Company Pharmacy and/or Provider received an incorrect payment. Company Pharmacy and/or Provider must request such adjustment no longer than one year from the date of service unless applicable law allows otherwise. Adjustments can be made by phoning the MHRx Pharmacy Help Desk or by writing to MHRx. When requesting an adjustment in writing, Company Pharmacy and/or Provider must submit the Statement of Claims showing the original dollar amount paid and a copy of the remittance advice. When appropriate, Company Pharmacy and/or Provider should include a short note and any wholesaler, manufacturer, or distributor invoices supporting the incorrect payment. MHRx reserves the right to charge up to $1.00 per claim for claim research fees that are associated with no change in reimbursement. MHRx may make an adjustment to any statement where it is indicated that Company Pharmacy and/or Provider received an incorrect amount for Company Pharmacy and/or Provider services provided. Claim Adjustments should be mailed to: MemberHealth, LLC Pharmacy Network Operations 29100 Aurora Road Solon, Ohio 44139

2.2 CO-PAYMENT/COINSURANCE Cost-Sharing or Cost-Sharing Amount, as defined in the Agreement must be collected by the Company Pharmacy and/or Provider from each Member as communicated via the TelePAID® System or other method established by MHRx. Company Pharmacy and/or Provider will not charge or collect from any Member any amount for Covered Prescription Services in excess of the applicable co-payment/coinsurance or other direct payment communicated by MHRx. Company Pharmacy and/or Provider acknowledges that the co-payment/coinsurance or other direct payment is an integral part of the plan design selected by the Part D Plan Sponsor, and Company Pharmacy and/or Provider will not waive or discount the applicable co-payment/coinsurance or other direct payment under any circumstances. 2.3 PRIOR AUTHORIZATION What Is Prior Authorization? At the request of some Part D Plan Sponsors, certain medications or classes of medications will require additional information to be obtained to determine whether the use or the quantity above stated plan limits is covered. Prior Authorization is a feature or a program that provides prescription benefit coverage if certain circumstances are met. Claim Message on Prior Authorization The following components on the claim message indicate that a Prior Authorization is needed: A reject code of "70" with message "drug not covered" or reject code "75" with message "prior authorization required." After the above claim information has been received, communicate to the Member the information outlined above in "What Is Prior Authorization?" Initiating Prior Authorization At times, a telephone number will be displayed along with the Prior Authorization claim message. The telephone number displayed will lead to MHRx's Prior Authorization unit or a Prior Authorization unit arranged by the Part D Plan Sponsor. · Contact the Prescriber and review the reason for the Prior Authorization. If required, the © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Prescriber can initiate a coverage review by contacting the toll-free number displayed on your screen. The Company Pharmacy and/or Provider and Member will also initiate the coverage review process by calling the toll-free number. When requested, MHRx Managed Care will fax the Prescriber a questionnaire. · If no telephone number is displayed on the claim reply, for a Prior Authorization you should refer the Member to the toll-free number for Member Services for further assistance. The Member's Member Services number can be found on the prescription benefit card. Communication of Benefit Decision Generally, the Member and Prescriber receive written confirmation of benefit decisions.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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SECTION 3.0 MANAGINGCLINICALMESSAGESA N D OPPORTUNITIES

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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3.1 CLINICAL PROGRAMS Clinical Messages Company Pharmacy and/or Provider is required to dispense prescriptions to Members in accordance with its pharmacist's professional judgment, quality practice standards, generic drug programs, formulary compliance, disease state management, and other clinical management programs implemented by MHRx as communicated to Company Pharmacy and/or Provider via the TelePAID® System and all applicable laws and regulations in accordance with Part D Plan Sponsor plan designs. These programs and initiatives are displayed to Company Pharmacy and/or Provider via the TelePAID® System. The following are descriptions of the various clinical messages and opportunities displayed via the TelePAID® System: · Drug Utilization Review ("DUR") Messaging · Clinical Management Programs · Maximum Daily Dosage ("MDD") / Drug-to-Drug Interaction · Refill Too Soon Edits · DUR Conflict, Intervention, and Outcomes Codes and Descriptions Drug Utilization Review ("DUR") 1. Company Pharmacy and/or Provider is required to operate a computer system that provides for the recording of patient drug and medical history, as allowed by law and sound pharmacy practice. MHRx may require that Company Pharmacy and/or Provider send to MHRx, via the TelePAID® System, other patient information as might be collected by the Company Pharmacy and/or Provider, under applicable state law, such as diseases, medical conditions, nonreimbursable medications (e.g., OTCs), and allergies. This information should be compatible with DUR messaging received via the TelePAID® System when a claim is being adjudicated. Messaging includes DUR, formulary, and intervention messages transmitted via the TelePAID® System. 2. Company Pharmacy and/or Provider is required, subject to professional judgment, to act upon DUR information provided by message alerts transmitted to Company Pharmacy and/or Provider via the TelePAID® System. The DUR messaging may not be complete; therefore, the Company Pharmacy and/or Provider should perform its own individual utilization review. Company Pharmacy and/or Provider's claims transmission system must comply fully with the current standard recognized by the NCPDP (see Glossary) Version 5.1. Company Pharmacy and/or Provider is required to provide intervention resolution and outcome codes to MHRx informing MHRx of the resolution of DUR alerts and messages transmitted via the TelePAID® System. The DUR Reason for Service, Professional Service, and Result of Service codes follow at the end of this section. These codes are also available from NCPDP and systems software vendors. Temporary Coverage Policy · Temporary Coverage is allowed for certain drugs that require prior authorization. · Pharmacists receiving a Primary Reject Error Code of "Drug Not Covered" or "Prior Authorization" (NCPDP Reject Error Codes 70, 75 or 76) may be able to obtain Temporary Coverage for Members for a limited supply of certain medications while awaiting the benefit decision. · If the drug qualifies for Temporary Coverage, a Secondary Reject Error Code message will be attached to the Primary Reject Error Code (see above). The Secondary Reject Error Code of "Temp Fill of XX D/S Allowable with PA/MC Override of XXXXX." Translated: Temporary Fill of `XX' Days Supply (Override Days Supply Value) Allowable with Prior Authorization/Managed Care Override of `XXXXX.'* o Important Note: If a possible DUR safety issue exists, contact the Prescriber to discuss the alert prior to processing the prescription using the Temporary Coverage Override. o If there is no safety issue, resubmit the prescription claim for the days' supply (D/S) provided in the reject message with the value of "01" in the NCPDP prior authorization type c ode field and "XXXXX" in the PA/MC field. © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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· Collect from the Member the indicated co-payment/coinsurance amount, if any. You will be reimbursed for the temporary supply of medication provided to your patient.

* "X" will have a numeric value. 3.2 DUR SPECIFICATION CODES General DUR Specification Codes DUR Reason for Service Codes and Descriptions: Represents the NCPDP code that identifies the reason for generating a DUR conflict. DUR Professional Service Codes and Descriptions: Represents the NCPDP code that identifies the intervention or action taken by a pharmacist to resolve a DUR conflict. DUR Result of Service Codes and Descriptions: Represents the NCPDP code that identifies the resolution (or outcome) associated with a DUR conflict. DUR Reason for Service Codes and Descriptions AD: Additional Drug Needed -- Optimal treatment of the patient's condition requires the addition of a new drug to the existing therapy. AN: Prescription Authentication -- Circumstances require that the pharmacist verify the validity and/or authenticity of the prescription. The principal use is for suspected fraud. AR: Adverse Drug Reaction -- First occurrence of an adverse reaction by a patient to a drug. AT: Additive Toxicity -- Detects drugs with similar side effects that could exhibit additive toxic potential. CD: Chronic Disease. CH: Call Help Desk -- Processor message to call help desk. CS: Patient Complaint/Symptom -- Patient presents to the pharmacist complaints or symptoms suggestive of illness requesting evaluation and treatment. DA: Drug Allergy -- Indicates that an adverse immune event may occur due to the patient's previously demonstrated heightened allergic response to the drug product in question. DC: Drug Disease (Inferred) -- Indicates that the use of the drug may be inappropriate in light of a specific medical condition that the patient has. The existence of specific medical condition may be inferred from drugs in the patient's medication history. DD: Drug-to-Drug Interaction -- Detects drug combinations in which the net pharmacological response may be different from the result expected when each drug is given separately. DF: Drug Food Interaction -- Detects interactions between a drug and certain foods. DI: Drug Incompatibility -- Identifies physical and chemical incompatibilities between two or more drugs. DL: Drug Lab Conflict -- Indicates that laboratory values may be altered due to the use of the drug, or that the patient's response to the drug may be altered due to a condition that is identified by a certain laboratory value. DM: Apparent Drug Misuse -- Pattern of drug use by a patient in a manner that is significantly different from that prescribed by the prescriber. DS: Tobacco Use -- Conflict detects when a prescribed drug is contraindicated or might conflict with the use of tobacco products. ED: Patient Education. ER: Overuse (Early Refill or Refill Too Soon) -- Detects prescription refills that occur before the days' supply of the previous filling should have been exhausted. EX: Excessive Quantity -- The quantity of dosage units prescribed is excessive for dispensing at a single time. © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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HD: High Dose (Exceeds Maximum Daily Dose) -- Detects drug doses that fall above the standard dosing range. IC: Iatrogenic Condition -- Detects possibly inappropriate use of drugs that are designed to ameliorate complications caused by another medication. ID: Ingredient Duplication -- Detects simultaneous use of drug products containing one or more identical generic chemical entities. LD: Low Dose (Under Minimum Daily Dose) -- Detects drug doses that fall below the standard dosing range. LK: Lock in Recipient. LR: Under Use -- Detects prescription refills that occur after the days' supply of the previous filling should have been exhausted. MC: Drug Disease (Reported/Actual) -- Indicates that the use of the drug may be inappropriate in light of a specific medical condition that the patient has. Information about the specific medical condition was provided by the prescriber, patient, or pharmacist. MN: Insufficient Duration -- Detects regimens that are shorter than the minimal limit of therapy for the drug product based on the product's common uses. MS: Missing Information/Clarification -- The prescription order is unclear, incomplete, or illegible with respect to essential information. MX: Excessive Duration -- Detects regimens that are longer than the maximal limit of therapy for the drug product based on the product's common uses. NA: Drug Not Available -- Drug is not currently available from any source. NC: Noncovered Drug Purchase. ND: New Disease/Diagnosis -- Patient has a newly diagnosed condition or disease that necessitates a professional pharmacy service. NF: Nonformulary Drug -- Drug is not included on the formulary of the patient's pharmacy benefit plan. This code is intended to support mandatory formulary enforcement activities by pharmacists. NN: Unnecessary Drug -- Drug is no longer needed by the patient. This code is intended to support ongoing monitoring of established drug therapy by the pharmacist, as distinguished from "Inappropriate drug/indication," which is intended to support prospective drug utilization review of new therapy. NP: New Patient Processing -- Initial interview and medication history of a new patient. NR: Lactation/Nursing Indication -- Drug is excreted in breast milk and may represent a danger to a nursing infant. NS: Insufficient Quantity -- Quantity of dosage units prescribed is insufficient. OH: Alcohol Conflict -- Detects when a prescribed drug is contraindicated or might conflict with the use of alcoholic beverages. PA: Drug Age -- Detects when a prescribed drug is contraindicated based on the patient's age. PC: Patient Question/Concern -- Request for information or concern expressed by the patient with respect to his or her care. PG: Drug Pregnancy -- Detects when a prescribed drug is contraindicated for use by a pregnant woman. This information is intended to assist in weighing the therapeutic value of a drug against possible adverse effects on the fetus. PH: Preventive Healthcare. PN: Prescriber Consultation -- Request by a prescriber for information or a recommendation related to the care of a patient. PP: Plan Protocol. PR: Prior Adverse Reaction -- Identifies those drugs to which the patient has previously reacted in an atypical manner. PS: Product Selection Opportunity -- An acceptable generic substitute or therapeutic equivalent exists for the drug. This code is intended to support discretionary drug product selection activities by pharmacists. RE: Suspected Environmental Risk. © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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RF: Health Provider Referral -- Patient referred to the pharmacist by another healthcare provider. SC: Suboptimal Compliance. SD: Suboptimal Drug/Indication -- Incorrect, inappropriate, or less than optimal drug prescribed for the patient's condition (should not be used when a more precise code exists to describe the problem, such as Drug Interactions, Drug Allergy, Drug Disease, etc.) SE: Side Effect -- Reports possible major side effects of the prescribed drug. SF: Suboptimal Dosage Form -- Incorrect, inappropriate, or less than optimal dosage form prescribed for the patient's condition. SR: Suboptimal Regimen -- Incorrect, inappropriate, or less than optimal dosing regimen prescribed for the patient's condition. SX: Drug Gender -- Detects when a prescribed drug is contraindicated or inappropriate for use based on the patient's sex. TD: Therapeutic Duplication -- Detects simultaneous use of different primary generic chemical entities that have the same therapeutic effect. TN: Laboratory Test Needed -- Assessment of the patient by the pharmacist suggested that a laboratory test is needed to optimally manage therapy. TP: Payer/Processor Question -- Request by a payer or processor for information related to the care of a patient. DUR Professional Service Codes and Descriptions AS: Patient Assessment -- Initial evaluation of a patient or complaint/symptom for the purpose of developing a therapeutic plan. CC: Coordination of Care -- Case management activities of a pharmacist related to the coordination of care being delivered by multiple providers. DE: Dosing Evaluation/Determination. FE: Formulary Enforcement -- Activities including interventions with prescriber and patients related to the enforcement of a pharmacy benefit plan formulary. GP: Generic Product Selection -- The selection of a product chemically and therapeutically identical to that specified by the prescriber for the purpose of achieving cost savings for the payer. MA: Medication Administration. MO: Prescriber Consulted -- Prescriber communication related to collection of information or clarification of a specific limited problem. MR: Medication Review -- Comprehensive review and evaluation of a patient's entire medication regimen. PO: Patient Consulted -- Patient communication related to collection of information or clarification of a specific limited problem. PE: Patient Education/Instruction -- Verbal and/or written communication by a pharmacist to enhance the patient's knowledge about the condition under treatment or to develop skills and competencies related to its management. PH: Patient Medication History -- Establishment of a medication history database on a patient to serve as the foundation for the ongoing maintenance of a medication profile. PM: Patient Monitoring -- Evaluation of established therapy for the purpose of determining whether an existing therapeutic plan should be altered. PR: Patient Referral -- Referral of a patient to another healthcare provider following evaluation by the pharmacist. PT: Perform Laboratory Test -- Pharmacist performs a clinical laboratory test on a patient. RO: Pharmacist Consulted Other Source -- Communication related to collection of information or clarification of a specific limited problem via professional judgment. RT: Recommend Laboratory Test -- Pharmacist recommends the performance of a clinical laboratory test on a patient. © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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SC: Self-Care Consultation -- Activities performed by a pharmacist on behalf of a patient intended to allow the patient to function more effectively on his or her own behalf in health promotion and disease prevention, detection, or treatment. Counseling a patient about the selection and use of an over-the-counter medication is probably the most common example of this type of service. SW: Literature Search/Review -- Pharmacist searches or reviews the pharmaceutical and/or medical literature for information related to the care of a patient. TC: Payer/Processor Consulted -- Communication by a pharmacist to a processor or payer related to the care of a patient. TH: Therapeutic Product Interchange -- The selection of a therapeutically equivalent product to that specified by the prescriber for the purpose of achieving cost savings for the payer. DUR Result of Service Codes and Descriptions · Filled As Is, False Positive -- Identified conflict determined not to be valid. · Filled Prescription As Is -- Identified conflict determined to be insignificant without contacting the prescriber. · Filled with Different Dose. · Filled with Different Directions. · Filled with Different Drug. · Filled with Different Quantity. · Filled with Prescriber Approval -- Conflict identified was valid and potentially significant. Resolution required consultation with the prescriber. · Brand to Generic Change -- Generic drug product was substituted for the prescribed branded product. · Rx to OTC Change -- An equally efficacious nonprescription drug product was dispensed in place of the prescribed product. · Filled with Different Dosage. · Prescription Not Filled. · Prescription Not Filled, Directions Clarified. · Recommendation Accepted -- Prescriber accepted the recommendation made by the pharmacist. · Recommendation Not Accepted -- Prescriber did not accept the recommendation made by the pharmacist. · Discontinued Drug -- Prescriber authorized the discontinuance of a drug. · Regimen Changed -- Prescriber authorized a change in dose or dosage regimen. · Therapy Changed -- Prescriber authorized a change in medication therapy. · Therapy Changed, Cost Increase Acknowledged -- Prescriber authorized a change in medication therapy recommended by the pharmacist that will increase the current cost of therapy with the goal of improving the overall healthcare outcome. · Drug Therapy Unchanged -- Prescriber did not authorize a change in medication therapy. · Follow-up/Report -- Verbal and/or written follow-up information was communicated from the pharmacist to the prescriber. · Patient Referral. · Instructions Understood. · Compliance Aid Provided. · Medication Administered.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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3.3 SUBMISSION CLARIFICATION CODES If Company Pharmacy and/or Provider receives a "refill too soon" rejection message, the following responses are appropriate: If the Member requests an "early refill" for no apparent reason, inform the Member of the plan limitations and let that Member know when the prescription can be refilled without a rejection. Use the Standard NCPDP override codes as follows: Submission Clarification Codes Value of "03" in Rx Clarification Field Value of "04" in Rx Clarification Field Value of "05" in Rx Clarification Field Note: · · · If the Submission Clarification Code is entered into the Pharmacy Software system and the claim rejects a second time, inform the Member that the plan has not approved an override for one of the three conditions indicated above. No default override codes are permitted on an initial inbound claim transaction. The reason for the override must be recorded on the original prescription. If an override is applied to more than one fill for the same prescription, the reason for each override use must be documented and dated. An automatically generated override code number, generated by the Pharmacy's Software system upon override code submission, is not considered documentation. Document on the hard-copy prescription: a) the reason for the override; b) the Authorization Code, if applicable; c) the name of the MHRx representative, if applicable. Utilization of any Submission Clarification Codes for reasons other than the intended purpose will result in the identification of audit discrepancies and charge backs. Definition Vacation supply refill Lost or spilled prescription Daily dosage, therapy changed by Prescriber

· ·

3 . 4 TelePAID® S U B M I S S I O N R E J E C T C O D E S Consult the NCPDP Data Dictionary Version 5.1 for a complete list of NCPDP reject codes for the telecommunication standard.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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SECTION 4.0 PRESCRIPTION SUBSTITUTION STANDARDS

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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4.1 GENERIC DRUG STANDARDS As part of MHRx's managed care initiatives, Company Pharmacy and/or Provider is required to use its best efforts in supporting MHRx and its Part D Plan Sponsors in managing the cost and quality of Covered Prescription Services by cooperating in administering mandatory generic programs as they may from time to time be contained in Part D Plan Sponsor benefit or MHRx programs. In practice, this means that Company Pharmacy and/or Provider will, in all cases, dispense generic drug products for multisource brand drugs, except where prohibited by applicable laws, rules, or regulations. Where the prescription does not authorize substitution, contact the Prescriber to reinforce plan guidelines and request authorization to change to an approved generic. 4.2 DISPENSE AS WRITTEN ("DAW") CODES The following NCPDP Standard DAW Codes are supported by MHRx. These Codes should be part of the claim record whenever a multisource brand drug product is dispensed. Proper use of the correct DAW Code is important for payment and co-payment/coinsurance processing. Follow the TelePAID ® System for reimbursement and co-payment/coinsurance information. Substitution with a generic product must always be in a manner consistent with applicable laws, rules, and regulations. DAW-0 No Product Selection Indicated This is a default field value that is appropriately used for prescriptions where selection is not an issue. Examples include prescriptions written for single-source brand products and prescriptions written using the generic name and a generic product is dispensed. Plans mandate that generic pricing be applied when DAW-0 is submitted for multisource brand medications. DAW-1 Substitution Not Allowed by Prescriber This value is used when the Prescriber indicates, in a manner specified by applicable laws, rules, and regulations, that the product is to be dispensed as written. This is subject to verification by MHRx at any time. DAW-2 Substitution Allowed -- Patient Requested Product Dispensed This value is used when the Prescriber has indicated, in a manner specified by applicable laws, rules, and regulations that generic substitution is permitted and the patient requests the brand product. This situation can occur when the Prescriber writes the prescription using either the brand or generic name and the product is available from multiple sources. Patient-requested brand must be documented on the prescription and may affect patient co-payment/coinsurance. DAW-3 Substitution Allowed -- Pharmacist Selected Product Dispensed This value is used when the Prescriber has indicated, in a manner specified by applicable laws, rules, and regulations, that generic substitution is permitted and the pharmacist determines that the brand product should be dispensed. This can occur when the Prescriber writes the prescription using either the brand or generic name and the product is available from multiple sources. Plans mandate that generic pricing be applied when DAW-3 is submitted for multisource brand medications. DAW-4 Substitution Allowed -- Generic Not in Stock This value is used when the Prescriber has indicated, in a manner specified by applicable laws, rules, and regulations that generic substitution is permitted and the brand product is dispensed since a currently marketed generic is not stocked in the pharmacy. This situation exists due to the buying habits of the pharmacist, not because of the availability of the generic product in the marketplace. Plans mandate that generic pricing be applied when DAW-4 is submitted for multisource brand medications. DAW-5 Substitution Allowed -- Brand Drug Dispensed as Generic © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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This value is used when the Prescriber has indicated, in a manner specified by applicable laws, rules, and regulations, that generic substitution is permitted and the pharmacist is utilizing the brand product as the generic entity. Plans mandate that generic pricing be applied when DAW-5 is submitted. DAW-6 Override NCPDP ­ Override Code with no meaningful application by MHRx. Plans mandate that generic pricing be applied when DAW-6 is submitted. DAW-7 Substitution Not Allowed -- Brand Drug Mandated by Law This value is used when the Prescriber has indicated, in a manner specified by applicable laws, rules, and regulations, that generic substitution is permitted, but prevailing law or regulation prohibits the substitution of a brand product even though generic versions of the product may be available in the marketplace. DAW-8 Substitution Allowed -- Generic Drug Not Available in Marketplace This value is used when the Prescriber has indicated, in a manner specified by applicable laws, rules, and regulations, that generic substitution is permitted and the brand product is dispensed since the generic is not currently manufactured, distributed, or is temporarily unavailable. Plans mandate that brand pricing be applied when DAW-8 is submitted for multisource brand medications. DAW-9 Other Reserved with no meaningful application by MHRx. Plans mandate that generic pricing be applied when DAW-9 is submitted. 4.3 FORMULARY DRUG STANDARDS Part D Plan Sponsors often adopt a formulary as part of their overall cost-containment programs, attempting to deliver a balance between cost management and quality of care. MHRx implements a variety of formulary programs for Part D Plan Sponsors. The most common formulary programs administered are Select and Optimal, which are supported by MHRx's independent Pharmacy & Therapeutics Committee. In addition, MHRx implements Part D Plan Sponsors' proprietary formulary programs. Company Pharmacy and/or Provider is required to support all formulary programs by dispensing formulary drugs to the maximum extent possible. Company Pharmacy and/or Provider must use best efforts to contact the Prescriber to encourage formulary compliance. Point-of-sale messaging is the primary vehicle for communicating formulary information to pharmacists and, thereby, to Members. Messaging is supplemented with other communications at the discretion and direction of the Part D Plan Sponsor. When Company Pharmacy and/or Provider transmits a claim consistent with the formulary, the claim adjudicates with the message "Formulary Rx." When a prescription is transmitted for a nonformulary drug product, the claim will either (i) reject, with the message "Non-Formulary Rx," for Part D Plan Sponsors utilizing a "Closed Formulary"; or (ii) will adjudicate, with the message "Non-Formulary Rx" in the approved message fields, for Part D Plan Sponsors utilizing an "Incentive or Open Formulary." Where appropriate, up to five formulary alternatives are displayed in the preferred product fields. If a prescription is submitted for a nonformulary drug and the Prescriber has not authorized a formulary drug alternative, the Company Pharmacy and/or Provider will inform the cardholder that the prescription is for a nonformulary drug and apply the co-payment/coinsurance, deductible, or other benefit requirement rules as transmitted via TelePAID ®. In some cases, the co-payment/coinsurance for a nonformulary drug may be higher if the plan is utilizing an "Incentive or Open Formulary" program. The Company Pharmacy and/or Provider is expected to cooperate with, administer, and dispense in accordance with, subject to the pharmacist's professional judgment, formulary compliance programs implemented by MHRx. It is inconsistent with MHRx Network standards if Company Pharmacy and/or Provider does not attempt to dispense in accordance with the formulary. Company Pharmacy and/or Provider is required to keep a record on the original prescriptions of its attempt at achieving formulary compliance. MHRx may recover from Company Pharmacy and/or Provider the full amount of Company Pharmacy and/or Provider's dispensing fees when © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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Company Pharmacy and/or Provider (i) fails to attempt formulary compliance or note formulary compliance efforts on the original prescription; (ii) acts contrary to formulary compliance; or (iii) causes the prescription to result in a higher cost to the Part D Plan Sponsor and/or the Member.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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SECTION 5.0 PR OFES SI ON AL A U DIT S

Inquiries regarding audits may be submitted in writing to: MemberHealth, LLC Process Integrity 29100 Aurora Rd Solon, Ohio 44139

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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SECTION 6.0 MISCELLANEOUS PROVIDER ISSUES

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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6.1 MISCELLANEOUS PROVIDER ISSUES Pharmacy must abide by this PSM. This PSM will be deemed a part of and incorporated into the Pharmacy's Agreement with MHRx as if fully set forth therein, and this PSM will be deemed included in any reference to Pharmacy's Agreement with MHRx. Any capitalized term set forth in this PSM, in the Regulatory Appendix, or in the Pharmacy's Agreement with MHRx will have the same meaning regardless of where the term is defined. Modifications by Pharmacy to any terms of this PSM shall not be binding upon the parties without the express written consent of MHRx. Pharmacy must maintain a copy of this PSM, the Pharmacy Agreement, and any contractual obligations with MHRx in order to ensure compliance. 6.2 ADVERTISING-INTELLECTUAL PROPERTY In addition to the Intellectual Property section of the Agreement, upon termination of Pharmacy's Agreement with MHRx, Pharmacy will immediately discontinue any references to being a MHRx provider and discontinue the use of any product names, company names, trade names, logos, product packaging and designs of MHRx or Part D Plan Sponsor. 6.3 CHANGE OF OWNERSHIP

MemberHealth must be notified of any change in control or ownership of a Provider or any of its locations when the Provider holds either a direct agreement with MemberHealth or an agreement through a PSAO or third-party contracting entity with MemberHealth. Stores being newly opened, closed, relocated, or acquired must also be reported to MemberHealth with the updated information. Three actions must be taken within 15 business days when a change in control of ownership occurs: If MemberHealth agreement is direct: 1) Report change to MemberHealth Contracts Administrator; obtain a new agreement under the new ownership; execute and return 2) Update Provider's information on file with NCPDP 3) If Provider is also contracted with Medco, Provider must complete their change in ownership process before processing for MemberHealth administered plans. If Provider is not contracted with Medco no action with Medco is required. If MemberHealth agreement is through PSAO or third-party contracting entity: 1) Report change to contracting representative; follow that organization's process to update information on-file with all contracted plans 2) Update Provider's information on file with NCPDP (based on guidance from PSAO or third-party contracting entity) 3) If Provider is also contracted with Medco, Provider must complete their change in ownership process before processing for MemberHealth administered plans. If Provider is not contracted with Medco no action with Medco is required.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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6.4 BEST AVAILABLE EVIDENCE SUBSIDY (LIS) POLICY (BAE) AND LOW INCOME

Best Available Evidence (BAE) Policy In accordance with CMS regulations, the best available evidence policy will be invoked when the Low Income Subsidy (LIS) information in CMS's systems for Medicare Part D enrollees does not appear to be correct and when: a. Medicare Part D enrollee or participating Pharmacy has evidence from the SSA, a state Medicaid agency that supports a more favorable LIS status for the enrollee or b. Medicare Part D enrollee claims to be subsidy eligible based on the full or partial dual eligible and cannot provide appropriate documentation Verify BAE contact information Pharmacy must contact Pharmacy Services at 866-684-5395 to validate whether: a. Member is enrolled under a Medicare Part D plan where Universal American is the Part D sponsor Steps to take when BAE discrepancy is believed to exist When BAE discrepancy is believed to exist, pharmacy must provide the following: a. Supportive documentation, if available (see below for details) b. If member has more or less than three (3) days of medication remaining a. If member has 3 or more days of medication remaining, indicate "Non-Immediate BAE Assistance Needed" b. If member has less than 3 days of medication remaining, indicate "Immediate BAE Assistance Needed" c. Member's Name (First, Last) d. Member's ID Number e. Member's Medicare Number (Health Insurance Claim Number ­ HICN) f. All documentation must include pharmacy's name, NPI number, NCPDP number, and a name of a pharmacy contact person and his/her telephone number or email address to facilitate a return response. Pharmacy may send all required documentation and information via: Fax to: 1-440-287-9798 Mail to: MemberHealth, LLC P.O. Box 5205 Rensselaer, NY 12144 Documentation: Any one of the following will be considered to be valid documentation: For Dual Eligible: © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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· · · · · ·

A copy of the beneficiary's Medicaid card that includes the beneficiary's name and an eligibility date during a month after June of the previous calendar year; A copy of a State document that confirms active Medicaid status during a month after June of the previous calendar year; A print-out from the State electronic enrollment file showing Medicaid status during a month after June of the previous calendar year; A screen print from the State's Medicaid systems showing Medicaid status during a month after June of the previous calendar year; Other documentation provided by the State showing Medicaid status during a month after June of the previous calendar year; or, For individuals who are not deemed eligible, but who apply and are found LIS eligible, a copy of the original SSA award letter-no reprints are allowed

For Institutionalized Individuals:

· · · A remittance from the facility showing Medicaid payment for a full calendar month for that individual during a month after June of the previous calendar year; A copy of State document that confirms Medicaid payment on behalf of the individual to the facility for a full calendar month after June of the previous calendar year; or A screen print from the State's Medicaid systems showing that individual's institutional status based on at least a full calendar month stay for Medicaid payment purposes during a month after June of the previous calendar year

LTC Pharmacies Only: From time to time, the Low Income Subsidy (LIS) eligibility information in CMS's systems for Medicare Part D enrollees may be updated retrospectively. When this occurs, LTC Pharmacy's attestation of noncollection of co-payments for Medicare Part D LIS enrollees who are members of a plan administered by MemberHealth, LLC on behalf will be required. Failure of LTC Pharmacy to attest to this noncollection of co-payments may result in MHRx holding reimbursing members of these cost-sharing amounts.

6.5 FREQUENTLY ASKED QUESTIONS Q: Can medications that require Prior Authorization be dispensed when MHRx's Prior Authorization Desk is unavailable? A: MHRx does have a Temporary Coverage Policy. For such a circumstance, see Temporary Coverage Policy Section of this PSM for details. Q: When I enroll in a specific MHRx Network, am I obligated to accept all programs for all cardholders using that Network? A: When you sign a network agreement, you are obligated to accept all programs for all cardholders using the Network in which you are enrolled. Termination from a Network can be accomplished by writing to the Network Management Department, MemberHealth, LLC, Pharmacy Support, 29100 Aurora Road, Solon, Ohio 44139. Q: Does the TelePAID ® System support fractional quantities of ophthalmic products and metered dose inhalers? A: Yes. Fractional quantities of medications must be sent through the TelePAID ® System for proper claims adjudication. For example, the 3.5-g tube of Bacitracin Ophthalmic Ointment must be reported in the "Quantity Dispensed" field as 3.5, not 4. Q: How does MHRx calculate the MDD for ointments, creams, and lotions? © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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A: MHRx calculates the MDD of ointments, creams, and lotions based on the use of 10 g of these external preparations per day. Q: What is the MDD for Imitrex ® 50 mg oral tablets? A: The MDD for Imitrex ® 50 mg oral tablets is considered to be 1.07 tablets per day. Stated another way: 32 tablets per 30 days; 96 tablets per 90 days. Q: What days' supply should be used for Premarin® 0.625 mg, No. 75, Sig: One tablet daily for days 1 to 25? A: The proper days' supply in this case is 90, not 75. Q: How does MHRx determine whether a drug product is a single-source, multisource brand, or generic? A: MHRx utilizes the definition of these categories based on an outside vendor's pricing data. Q: What should I do if I don't receive my biweekly check from MHRx? A: Call the MHRx Pharmacy Services Help Desk at 866-684-3057. Q: Whom do I call if I have a compounding or DUR question that only a pharmacist can answer? A: Call the MHRx Pharmacy Services Help Desk at 866-684-5395. Q: How do I report the correct days' supply (DS) on a prescription for four tablets of a drug with the directions of 1 tablet per week? A: The DS should be reported as 28 days. Q: How do I contact MHRx if I have a grievance regarding service MHRx has provided? A: You must submit your grievance in writing to: MemberHealth, LLC Pharmacy Network Operations 29100 Aurora Road Solon, Ohio 44139

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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6.6 GLOSSARY Medicare Drug Plan Formulary: A standard drug formulary developed by the P&T Committee which lists Covered Part D Drugs by therapeutic category and identifies their relative costs, as adopted for use by Medicare Part D Members. Medicare Part D Member or Member: An individual who is enrolled in a MA-PD Plan or a PDP Plan offered by a Part D Plan Sponsor. NCPDP Standard: TelePAID ® claims are submitted to MHRx in accord with the standard Version 5.1 or the then-current standard version as established by the: National Council for Prescription Drug Programs Inc. 9240 East Raintree Drive Scottsdale, Arizona 85260 Phone Number: 1 480 477-1000 Fax Number: 1 480 767-1042 Prescriber: A licensed practitioner with the legal authority to initiate a prescription drug order in the course of professional practice for an Member. Prescribers generally refer to: licensed physicians, podiatrists, and physician extenders but may include other practitioners as well. Coverage of prescription drugs and other medical products and services may vary by type of prescriber, plan sponsors' plan designs, and applicable state law. Secure Fax Number: A Secure Fax Number is defined as a pharmacy fax number that is secure enough to receive confidential patient information and is not available to the general public nor to any nonprofessional pharmacy staff. TelePAID® System: TelePAID ® is the online claims submission and processing system used for the adjudication of all MHRx claims for Members. TelePAID ® System claims are submitted only for the Member for whom the prescription is intended. 6.7 MHRX CLAIMS CYCLE AND PAYMENTS The Pharmacy will be reimbursed for valid payable claims transmitted electronically through the TelePAID® System according to a specified bi-weekly claim cycle. MHRx will reimburse for claims pursuant to the terms of the Agreement and the cycle listed below for 2010.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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MHRx Claims Cycle Schedule 2010

Claims Cycle Start 12/26/09 01/02/10 01/09/10 01/16/10 01/23/10 01/30/10 02/06/10 02/13/10 02/20/10 02/27/10 03/06/10 03/13/10 03/20/10 03/27/10 04/03/10 04/10/10 04/17/10 04/24/10 05/01/10 05/08/10 05/15/10 05/22/10 05/29/10 06/05/10 06/12/10 06/19/10 06/26/10 07/03/10 07/10/10 07/17/10 07/24/10 07/31/10 08/07/10 08/14/10 08/21/10 08/28/10 09/04/10 09/11/10 09/18/10 09/25/10 10/02/10 10/09/10 10/16/10 End 01/01/10 01/08/10 01/15/10 01/22/10 01/29/10 02/05/10 02/12/10 02/19/10 02/26/10 03/05/10 03/12/10 03/19/10 03/26/10 04/02/10 04/09/10 04/16/10 04/23/10 04/30/10 05/07/10 05/14/10 05/21/10 05/28/10 06/04/10 06/11/10 06/18/10 06/25/10 07/02/10 07/09/10 07/16/10 07/23/10 07/30/10 08/06/10 08/13/10 08/20/10 08/27/10 09/03/10 09/10/10 09/17/10 09/24/10 10/01/10 10/08/10 10/15/10 10/22/10

CCRx Payment Date Friday, January 08, 2010 Friday, January 15, 2010 Friday, January 22, 2010 Friday, January 29, 2010 Friday, February 05, 2010 Friday, February 12, 2010 Friday, February 19, 2010 Friday, February 26, 2010 Friday, March 05, 2010 Friday, March 12, 2010 Friday, March 19, 2010 Friday, March 26, 2010 Friday, April 02, 2010 Friday, April 09, 2010 Friday, April 16, 2010 Friday, April 23, 2010 Friday, April 30, 2010 Friday, May 07, 2010 Friday, May 14, 2010 Friday, May 21, 2010 Friday, May 28, 2010 Friday, June 04, 2010 Friday, June 11, 2010 Friday, June 18, 2010 Friday, June 25, 2010 Friday, July 02, 2010 Friday, July 09, 2010 Friday, July 16, 2010 Friday, July 23, 2010 Friday, July 30, 2010 Friday, August 06, 2010 Friday, August 13, 2010 Friday, August 20, 2010 Friday, August 27, 2010 Friday, September 03, 2010 Friday, September 10, 2010 Friday, September 17, 2010 Friday, September 24, 2010 Friday, October 01, 2010 Friday, October 08, 2010 Friday, October 15, 2010 Friday, October 22, 2010 Friday, October 29, 2010

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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MHRx Claims Cycle Schedule 2010 (continued)

Claims Cycle Start 10/23/10 10/30/10 11/06/10 11/13/10 11/20/10 11/27/10 12/04/10 12/11/10 12/18/10 End 10/29/10 11/05/10 11/12/10 11/19/10 11/26/10 12/03/10 12/10/10 12/17/10 12/24/10

CCRx Payment Date Friday, November 05, 2010 Friday, November 12, 2010 Friday, November 19, 2010 Friday, November 26, 2010 Friday, December 03, 2010 Friday, December 10, 2010 Friday, December 17, 2010 Friday, December 24, 2010 Friday, December 31, 2010

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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SECTION 7.0 ADDITIONAL COMPLIANCE REQUIREMENTS

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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7.1 Fraud, Waste, and Abuse Training: CMS regulations require that all entities that support Medicare Part D activities are fully aware of the need to detect, correct, and prevent Fraud, Waste, and Abuse ("FWA"). CMS does not dictate how plans or pharmacies go about implementing a FWA program; it simply offers guidelines on what constitutes acceptable training topics. To fulfill this requirement, pharmacies must train their employees through one of the following accepted training modules. Training must be conducted every calendar year. Pharmacy may locate training modules as follows: · · Universal American's (MHRx's parent company) Part D Fraud, Waste and Abuse training module can be found at: http://2010.mhrx.com/pdfs/medicare_part_d_fwa_training.pdf Pharmacy may use an alternative training program that addresses at a minimum the following topics: · Compliance with Federal statutes (i.e., False Claims Act, Anti-Kickback Statute, HIPAA, etc.) · Requirement to have appropriate policies and procedures to address fraud, waste, and abuse · Types of fraud, waste and abuse that can occur, including but not limited to: Inappropriate billing practices Bait and switch pricing Prescription altering Dispensing expired or altered prescription drugs Illegal remuneration True Out of Pocket (TrOOP) manipulation · Incorrect or misleading notices to enrollees · U.S. Office of Inspector General (OIG) exclusion list · Process for reporting fraud, waste and abuse · Protections in non retaliation for employees who report suspected fraud, waste and abuse

Fraud and abuse can be committed by beneficiaries, pharmacies, physicians, third parties, or a combination of all. If you suspect someone has committed fraud, waste or abuse against a Part D Plan Sponsor or MHRx, or think you may be a victim, please report the suspicious activity. Please report fraud, waste or abuse for Community CCRxSM by calling 1-866-684-5353 or in writing to: Community CCRxSM ­ FWA Unit P.O. Box 5205 Rensselaer, NY 12144-5205 Anonymous reports can be made for either plan by calling the Part D Fraud, Waste and Abuse toll-free hotline at 1-866-684-0595. All reports are confidential. © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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7.2 Formulary Change Notification Changes to a plan's formulary made during the coverage year, including drugs being removes from the formulary, the addition of prior authorization, quantity limits and/or step therapy restrictions on a drug, and/or drugs being moved to a higher cost-sharing tier, will only be provided on the following website http://[email protected]/providers/formulary_changes. These formulary change notices will be posted on said website at least 60 days before the date the formulary change becomes effective. However, if the Food and Drug Administration deems a drug on any of the formularies to be unsafe, or if the drug manufacturer removes the drug from the market, we will immediately remove the drug from the formulary and posting of the notice may be retrospective on the website. 7.3 CMS Provider Marketing Guidelines for Pharmacies and Pharmacists The 2010 Annual Election Period for Medicare Advantage and Medicare Part D is fast approaching. Listed here are Medicare guidelines that govern how you can and cannot inform or educate customers about enrollment and plan information. To the extent that you are able to assist a beneficiary in an objective assessment of his or her needs, and potential plan options that may meet those needs, CMS encourages you to do so. CMS is concerned, however, that providers may not at times be fully aware of all plan benefits and costs and that beneficiaries may be confused if they perceive their pharmacist is acting on behalf of a plan. So, it is important that you adhere to the Medicare guidelines, stay informed, and act always in the best interest of your patients when responding to request for assistance or advice. Providers Can · Distribute CMS- approved Plan Finder information. You may also share information with patients from the CMS Web site, www.cms.gov and/or the Medicare Web site, www.medicare.gov Or have patients call 1-800-MEDICARE. · Display promotional materials that announce your relationship with a plan. You must display these materials equally for ALL plans with which you are affiliated that have provided you with such materials. · Make available printed information provided by a plan sponsor to your patients, as long as there is no "ranking," "highlighting" or comparison of specific plans. (If you accept and display information for one plan, you must accept and display information for ALL plans with which you are affiliated that have provided you these materials.) · Provide contact information for any plan which a beneficiary expresses an interest and requests such contact information from you. However, the beneficiary must contact the plan or plan agent directly and you should not make referrals to the plan or plan agent. · Make available PDP marketing materials and enrollment applications. You may also make available plan information about Medicare Advantage plans (MA) and Medicare Advantage Plans combined with prescription drug coverage (MA-PD). You cannot, however, distribute MA or MA-PD enrollment applications. · Use direct mail and/or e-mail to announce a new plan affiliation -- but only once. Additional communications must include ALL plans with which you are affiliated. · Provide information and assistance to your patients in applying for the low income subsidy. Providers CANNOT · Direct, urge, persuade, steer or offer inducements to join a particular plan. · Compare plan benefits against other health plans, unless the materials were written or approved by CMS (for example, information generated through CMS' Plan Finder via a © 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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computer terminal for access by beneficiaries). Make available PDP enrollment forms at the counter. Collect or accept Medicare enrollment applications of any kind. Offer sales or appointment forms. Mail marketing materials on behalf of a plan. Make available third party sales or plan promotional materials that are not CMS -approved. Expect or accept compensation for conducting enrollment or marketing activities. Suggest that a particular plan is approved, endorsed or authorized by Medicare. Make or distribute plan information, including PDP enrollment forms, during health screenings.

· · · · · · · ·

Agents In Store CANNOT · Conduct sale activities in close proximity to the pharmacy counter or pharmacy consulting area. · Accept PDP, MA, or MA-PD applications in areas where patients primarily receive healthcare services. For additional information, see the Medicare Marketing Guidelines, available at: http://www.cms.hhs.gov/ManagedCareMarketing/Downloads/R91MCM.pdf 7.4 Medicare Prescription Drug Coverage And Your Rights Pharmacy is required to conspicuously post the notice on the following page regarding each Member's drug coverage rights.

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS

You have the right to request a coverage determination and get a written explanation from your Medicare drug plan if: · Your prescriber or pharmacist tells you that your Medicare drug plan will not cover a prescription drug in the amount or form prescribed; or · You are asked to pay a different cost-sharing amount than you think you are required to pay for a prescription drug. You also have the right to ask your Medicare drug plan for an exception (a special type of coverage determination) and get a written explanation from your Medicare drug plan if: · You believe you need a drug that is not on your drug plan's list of covered drugs. The list of covered drugs is called a "formulary;" · You believe a coverage rule (such as prior authorization or a quantity limit) should not apply to you for medical reasons; or · You believe you should get a drug you need at a lower cost-sharing amount. What you need to do: · Contact your Medicare drug plan to ask for a coverage determination, including an exception request. · Refer to the benefits booklet you received from your Medicare drug plan or call 1-800-MEDICARE to find out how to contact your drug plan. · When you contact your Medicare drug plan, be ready to tell them: · The prescription drug(s) that you believe you need. · Include the dose and strength, if known. · The name of the pharmacy or prescriber who told you that the prescription drug(s) is not covered. · The date you were told that the prescription drug(s) is not covered. The Medicare drug plan's written explanation will give you the specific reasons why the prescription drug is not covered and will explain how to request an appeal if you disagree with the drug plan's decision. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0975. The time required to complete this information collection is estimated to average one minute per response, including the time to select the preprinted form, and hand it to the enrollee. If you have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form No. CMS-10147 (10/31/2011)

© 2009-2010 MemberHealth, LLC. All rights reserved. TelePAID® is a registered trademark of Medco Health Solutions, Inc. ©2009 Medco Health Solutions, Inc. All rights reserved.

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