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1 Last revision date: 2181 E. Aurora Road, Suite 201 | Twinsburg, OH 44087 Copyright 2012, EnvisionRx. All rights reserved. Version 28 Provider Portal Supplemental Policies, Procedures and Regulations Prepared by: EnvisionRx 800-361-4542 This document contains detailed explanations of certain conditions of participation in the EnvisionRx Pharmacy Network. Procedures are outlined for the electronic submission of Pharmacy Claims. Also contained are helpful contact numbers, payment terms, answers to common questions and our pricing and reimbursement process. 1 *This page was intentionally left blank* 2 Proprietary and Confidential The information contained in this document is privileged and confidential property of EnvisionRx. This document cannot be reproduced or transmitted in any form without the written approval of EnvisionRx.

2 If you are not the intended viewer, or have viewed this document in error, please notify EnvisionRx immediately and delete all copies of this document, including any attachments, without reading them or saving them to disk. If you are the intended viewer, you must secure the contents of this document in accordance with all applicable state or federal requirements related to the privacy and security of information, including the HIPAA Privacy guidelines. The information contained herein is for informational, evaluative, or educational purposes only and is not legal, regulatory compliance, health/medical, or financial advice. The financial information or projections contained herein are an estimate for evaluative purposes only and not a statement of any future financial performance or results.

3 Advertising Requests Pharmacy providers are expressly denied any rights to use the EnvisionRx name, likeness, logo or other forms of advertisement without prior, written consent from EnvisionRx. This applies to all advertisements that reference EnvisionRx in any way regardless of the advertising medium. To request permission, submit a copy of the advertisement if printed medium or script, if radio, TV, or cable, via fax to Provider Relations at 330-405-8094. In the request, the Pharmacy Provider must include the Pharmacy contact name and telephone number, reason for the advertisement, duration and market(s) where the advertisement will be placed. Approval or denial by EnvisionRx will be communicated in writing to the requesting Pharmacy once internal review is completed.

4 Note that any advertising designed to waive or discount participant Cost Share (copayments, coinsurances or deductibles) will automatically not be approved. 3 Table of Contents GENERAL INFORMATION .. 6 CONTACT INFORMATION / WHERE TO GET HELP .. 6 OTHER IMPORTANT PHONE NUMBERS .. 7 NETWORK APPLICATION AND CREDENTIALING GUIDELINES .. 7 APPLYING FOR PARTICIPATION .. 7 CREDENTIALING GUIDELINES .. 7 NETWORK PHARMACY CONTRACTING .. 8 NON-PREFERRED VS. PREFERRED STATUS .. 8 Provider AND MEMBER SERVICE STANDARDS .. 8 NON-DISCRIMINATION CLAUSE .. 8 Provider NETWORK - ACCESSIBILITY .. 8 MEMBER COMMUNICATION .. 9 PHARMACY COMMUNICATION .. 9 QUALITY ASSURANCE .. 9 NETWORK PHARMACY COMPLAINT PROCESS .. 9 COMPLIANCE WITH LAWS .. 9 INVESTIGATIONS AND DISCIPLINARY ACTIONS .. 9 CHANGE OF INFORMATION.

5 9 SUSPENSIONS AND TERMINATIONS .. 10 EXCLUDED PARTIES .. 10 FRAUD, WASTE AND ABUSE TRAINING .. 11 PROCESSING A CLAIM .. 11 BIN NUMBER AND PCN INFORMATION .. 11 ELECTRONIC CLAIMS TRANSMISSIONS REQUIREMENT .. 11 ACCURATE CLAIM SUBMISSION AND PRESCRIPTION RECORD .. 12 COMPOUND PRESCRIPTION DEFINITION .. 14 COMPOUND PRESCRIPTION CLAIM SUBMISSION .. 14 REIMBURSEMENT AND COST SHARE .. 15 ALL LINES OF BUSINESS .. 15 INITIATED PRESCRIPTIONS .. 15 IDENTIFICATION CARDS .. 15 EDITS .. 16 FRAUD WASTE AND ABUSE EDITS .. 16 DRUG UTILIZATION REVIEW (DUR) EDITS .. 16 4 COORDINATION OF BENEFITS (COB) .. 17 AUDIT GUIDELINES .. 17 INTRODUCTION .. 18 TYPES OF AUDITS .. 18 REQUESTED DOCUMENTATION AND RECORDS .. 18 TYPICAL AUDIT PROTOCOL AND APPEALS PROCESS .. 19 FREQUENTLY ASKED QUESTIONS .. 19 ACCEPTABLE AUDIT APPEALS .. 21 CONTACT.

6 23 DEFINITIONS .. 23 HOW TO REPORT SUSPECTED FRAUD .. 24 MEDICARE PART D .. 24 MEDICARE COVERAGE GAP DISCOUNT PROGRAM .. 24 WHAT ARE APPLICABLE DRUGS? .. 24 HOW WILL THE MEDICARE COVERAGE GAP DISCOUNT PROGRAM WORK? .. 24 HOW WILL MY PHARMACY KNOW WHICH MANUFACTURERS HAVE SIGNED A COVERAGE GAP DISCOUNT PROGRAM AGREEMENT WITH CMS? .. 25 MEDICARE AUDIT AND RECORD RETENTION REQUIREMENTS .. 25 REJECTIONS .. 25 PART D UNIQUE BIN REQUIREMENTS .. 27 TRANSITION REQUIREMENTS .. 27 MEDICARE PRESCRIPTION DRUG COVERAGE AND YOUR RIGHTS REVISED GUIDANCE FOR DISTRIBUTION OF STANDARDIZED PHARMACY NOTICE (CMS-10147) .. 28 HOSPICE MEDICATIONS .. 31 PRESCRIBER VERIFICATION .. 32 LONG TERM CARE PHARMACY (LTC) .. 32 SHORT CYCLE DISPENSING .. 33 2014 REQUIREMENTS FOR CODING PATIENT RESIDENCE AND PHARMACY SERVICE TYPE ON CLAIM 35 2014 DAILY COST SHARING REQUIREMENTS.

7 35 ADDITIONAL MEDICARE PART D REQUIREMENTS .. 36 VACCINES .. 37 RETAIL VACCINE PROCESSING INSTRUCTIONS .. 38 VACCINE PROGRAM LIST .. 38 PRICING AND REIMBURSEMENT QUESTIONS .. 40 MAXIMUM ALLOWABLE COST (MAC) .. 40 5 STATE SPECIFIC PROVISIONS .. 41 NEW HAMPSHIRE - MEDICAID LINE OF BUSINESS .. 41 NEW JERSEY - COMMERCIAL LINE OF 46 WISCONSIN - MEDICAID LINE OF BUSINESS .. 47 TEXAS - NETWORK ADMINISTRATION TECHNOLOGY FEE (NATF) .. 47 ACRONYMS .. 48 6 GENERAL INFORMATION This Provider Portal of our Policies, Procedures and Regulations is designed to offer you, our participating Pharmacy providers, with important information regarding our program requirements and our operational procedures. Participating Pharmacy providers that sign our Participating Provider Agreement (PPA) are contractually bound to comply with the terms of these Policies, Procedures and Regulations.

8 As a participating Pharmacy Provider , you will receive a fully signed PPA. If your Pharmacy has not received its copy of the PPA, or if you have any questions regarding the PPA, please call our Pharmacy Help Desk at 800-361-4542 (TTY Users may call 711). All Pharmacies are expected to adhere to the PPA terms. Failure to comply could result in the termination of your PPA by EnvisionRx. EnvisionRx credentials potential Pharmacy providers prior to their acceptance in any EnvisionRx Network. EnvisionRx monitors the credentials of its providers in accordance with EnvisionRx policies, acceptable industry standards and/or as mandated by law. Pharmacy providers must respond promptly to provide EnvisionRx with any requested documentation necessary to in order to maintain its participation status.

9 Any updates to your Pharmacy s mailing or location address, telephone number, payment addresses etc., must be submitted to NCPDP for any Pharmacy update submissions. EnvisionRx reserves the right to update this document from time to time. The latest copy of the Provider Portal can be found at under Provider . CONTACT INFORMATION / WHERE TO GET HELP The Pharmacy Help Desk is available 24 hours a day, 7 days a week, 365 days per year including holidays, at: 800-361-4542 (TTY Users may call 711). The Pharmacy Help Desk is available to assist with billing/payment inquiries, Claims and formulary questions, disputes and appeals, Member/plan benefits, Member eligibility, Pharmacy Network issues, and prior authorizations. If a Pharmacy has suggestions as to how the Network can better serve our Members, they can contact the Pharmacy Help Desk as well.

10 If a Member has a general or clinical question or a dispute regarding a Claim, please refer them to our Customer Service number located on the reverse side of their membership card. Members in the program should be directed to call the number on the back of their card (TTY Users may call 711). If your Pharmacy has a question regarding an accounting issue such as payments, EFT set up, etc., send an email to EnvisionRx at If your Pharmacy has a question regarding MAC drug pricing, email EnvisionRx at 7 OTHER IMPORTANT PHONE NUMBERS Department Phone Number Report Fraud Waste & Abuse (866) 417-3069 Dispute Resolution (800) 361-4542 Coverage Determinations (800) 361-4542 NETWORK APPLICATION AND CREDENTIALING GUIDELINES APPLYING FOR PARTICIPATION To apply to become a participating Pharmacy, the applicant can fill out the online new participating Pharmacy enrollment application at #IndependentPharmacyEnrollment or call the Pharmacy Help Desk at 800-361-4542 (TTY Users may call 711).