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Last revision date: 7.23.2020Pharmacy ManualSupplemental Policies, Procedures and RegulationsPrepared by:EnvisionRx800-361-4542WWW.ENVISIONRX.COM2181 E. Aurora Road, Suite 201 Twinsburg, OH 44087Copyright 2012, EnvisionRx. All rights reserved.Version 38

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Table of ContentsPHARMACY MANUAL INTRODUCTION. 4GENERAL INFORMATION . 4PROPRIETARY AND CONFIDENTIAL . 4ADVERTISING REQUESTS . 5CONTACT INFORMATION / WHERE TO GET HELP . 5NETWORK ENROLLMENT FORM AND CREDENTIALING GUIDELINES. 5APPLYING FOR PARTICIPATION . 5C REDENTIALING G UIDELINES . 6QUARTERLY PROVIDER CREDENTIALING AUDITS. 6PROVIDER AND MEMBER SERVICE STANDARDS. 6N ON-D ISCRIMINATION C LAUSE . 6PROVIDER NETWORK – ACCESSIBILITY . 7PHARMACY C OMMUNICATIONS . 7N ON-PREFERRED VS . PREFERRED STATUS . 7Q UALITY ASSURANCE . 7C OMPLIANCE WITH LAWS . 7INVESTIGATIONS AND DISCIPLINARY ACTIONS . 7C HANGE OF INFORMATION . 8EXCLUDED PARTIES . 8F RAUD , WASTE AND ABUSE T RAINING . 8SUSPENSIONS AND TERMINATIONS . 8PRICING AND REIMBURSEMENT QUESTIONS . 10REIMBURSEMENT AND COST SHARE . 10MAXIMUM ALLOWABLE COST (MAC) . 10MAC LISTS . 10MAXIMUM ALLOWABLE COST APPEALS . 10VACCINES . 11R ETAIL VACCINE PROCESSING INSTRUCTIONS. 11VACCINE PROGRAM L IST . 11PROCESSING A CLAIM . 13BIN N UMBER AND PCN INFORMATION . 13ELECTRONIC C LAIMS T RANSMISSIONS R EQUIREMENT . 13ACCURATE CLAIM SUBMISSION AND PRESCRIPTION RECORD . 14AUDIT GUIDELINES. 18INTRODUCTION . 18T YPES OF AUDITS . 18R EQUESTED D OCUMENTATION AND R ECORDS . 19T YPICAL AUDIT PROTOCOL AND APPEALS PROCESS . 19WHOLESALER , M ANUFACTURER AND D ISTRIBUTOR INVOICES : REQUIREMENTS AND AUDITS . 20F REQUENTLY ASKED AUDIT Q UESTIONS . 202

ACCEPTABLE AUDIT APPEALS. 22D EFINITIONS . 25EDITS . 25F RAUD WASTE AND ABUSE EDITS . 25D RUG UTILIZATION R EVIEW (DUR) EDITS . 26POINT OF SALE ( POS ) OPIOID PATIENT SAFETY EDITS . 27COORDINATION OF BENEFITS ( COB ) . 28MEDICARE PART D . 29M EDICARE C OVERAGE G AP D ISCOUNT PROGRAM . 29WHAT ARE “APPLICABLE ” D RUGS? . 29H OW WILL THE M EDICARE C OVERAGE G AP D ISCOUNT PROGRAM WORK ? . 29H OW WILL MY PHARMACY KNOW WHICH MANUFACTURERS HAVE SIGNED A COVERAGE GAP DISCOUNT PROGRAMAGREEMENT WITH CMS? . 30M EDICARE AUDIT AND R ECORD R ETENTION R EQUIREMENTS . 30R EJECTIONS . 30PART D U NIQUE BIN R EQUIREMENTS. 31T RANSITION R EQUIREMENTS . 32M EDICARE PRESCRIPTION D RUG COVERAGE AND YOUR R IGHTS – R EVISED G UIDANCE FOR D ISTRIBUTION OFSTANDARDIZED PHARMACY N OTICE (CMS-10147) . 33MAIL ORDER PHARMACIES . 33HOME INFUSION PHARMACIES . 34HOME INFUSION PHARMACY NPPES REGISTRATION . 34PHARMACIES SERVICING LONG TERM CARE FACILITIES . 34H OSPICE MEDICATIONS . 35PRESCRIBER VERIFICATION . 36L ONG T ERM C ARE PHARMACY (LTC) . 37SHORT C YCLE D ISPENSING . 37R EQUIREMENTS FOR CODING PATIENT R ESIDENCE AND PHARMACY SERVICE T YPE ON C LAIM T RANSACTIONS . 38D AILY C OST SHARING R EQUIREMENTS . 39M EDICARE PART D AUTO REFILL . 40ADDITIONAL M EDICARE PART D REQUIREMENTS . 40STATE SPECIFIC PROVISIONS . 41C ALIFORNIA – M ANAGED H EALTH C ARE . 41N EW H AMPSHIRE - M EDICAID L INE OF BUSINESS . 41N EW JERSEY - C OMMERCIAL L INE OF BUSINESS . 46NORTH C AROLINA – FULLY- INSURED COMMERCIAL AND HMO LINE OF BUSINESS . 47T EXAS - N ETWORK ADMINISTRATION T ECHNOLOGY FEE (NATF) . 47WISCONSIN - M EDICAID L INE OF BUSINESS . 47ACRONYMS . 493

PHARMACY MANUAL INTRODUCTIONThe Pharmacy Manual (Pharmacy Manual may also be referred to in the Participating Provider Agreement asProvider Portal) outlines the policies, procedures, and regulations for Pharmacies participating in the EnvisionRxNetwork. This Manual provides information that Pharmacies in the Network must follow in addition to the provisionsincluded in the Participating Provider Agreement (PPA). Pharmacies can reference the Pharmacy Manual and utilizethe information to ensure quality service to Members. Pharmacies participating in the Network are obligated toreview the Pharmacy Manual regularly and ensure compliance of Pharmacy staff members.We thank you for continued cooperation and participation in our Network.GENERAL INFORMATIONEnvisionRx is a Pharmacy Benefits Manager (PBM) with headquarters located in Twinsburg, OH.This Pharmacy Manual, including our policies, procedures and regulations, is designed to offer Pharmacies, withimportant information regarding program requirements and operational procedures. Pharmacies that sign our PPA arecontractually bound to comply with the terms as it is incorporated into and a part of your PPA. All Pharmacies areexpected to adhere to the PPA terms. Failure to comply may result in the termination of your PPA by EnvisionRx.EnvisionRx credentials potential pharmacies prior to their acceptance in any EnvisionRx Network. EnvisionRx monitorsthe credentials of its Pharmacies in accordance with EnvisionRx policies, acceptable industry standards and/or asmandated by law. Pharmacies must respond promptly to provide EnvisionRx with any requested documentationnecessary to in order to maintain its participation status in the network.Depending on the line of business, certain sections of the Pharmacy Manual will apply (i.e. Medicare, HMA, Exchange).Capitalized terms used in the Pharmacy Manual but not defined herein shall have the same meaning as set forth in thePPA. This Pharmacy Manual supersedes and replaces all previous versions of the Pharmacy Manual. EnvisionRx doesnot require Pharmacy or PSAO approval prior to revising or modifying the Pharmacy Manual. Pharmacy shall alsomean PSAO contracting on behalf of Pharmacy (as applicable).EnvisionRx receives all Pharmacy information updates through National Council for Prescription Drug Programs(NCPDP). To make updates to information including address, email, fax number, phone number, chain/PSAOaffiliation, payment center, and other important information, visit NCPDP’s website at online.ncpdp.org. It is theresponsibility of the Pharmacy to provide timely updates to NCPDP to ensure that EnvisionRx has the most accurateand updated data.EnvisionRx reserves the right to update this document from time to time.P ROPRIETARY AND CONFIDENTIALThe information contained in this Pharmacy Manual is privileged and confidential property of EnvisionRx and is forbusiness purposes only. The Pharmacy Manual is not nor should it be considered legal, compliance, medical/health,or financial advice. The Pharmacy Manual cannot be copied, reproduced, transmitted or otherwise used or disclosedin any form without the written approval of EnvisionRx or as authorized in the PPA.4

ADVERTISING REQUESTSPharmacies are expressly denied any rights to use the EnvisionRx name, likeness, logo, service marks, ortrademarks in any advertisement, promotion, or otherwise without prior, written consent from EnvisionRx. NoteEnvision Rx will not approve any advertisement or promotional materials that is designed to waive or discountparticipant Cost Share (copayments, coinsurances or deductibles). The Pharmacy will immediately discontinue use ofapproved advertisement, promotion or otherwise if suspended or terminated from the Pharmacy Network.CONTACT INFORMATION / WHERE TO GET HELPThe Pharmacy Help Desk is available 24 hours a day, 7 days a week, 365 days per year including holidays at: 800361-4542 (TTY Users may call 711). Pharmacies may also reference the phone number provided in the claim responsemessaging or on the back of the Member ID card. Below is the contact information for each department and the typesof inquires they are responsible for. For questions on topics that are not listed below, please contact our PharmacyHelp Desk. If a Pharmacy has suggestions as to how EnvisionRx can better serve our Members, they can completethe Pharmacy Satisfaction Survey.DepartmentAccounts PayableFraud, Waste, and AbuseHotlineInquiry TypePayments, electronic funds transfer (EFT) and electronicremittance advice (ERA)Report suspected fraud, waste and abuse and othercompliance related issuesContact rx.comPhone: 1-866-417-3069Online: myethicsline.envisionrx.comMACMAC drug pricing and appealsEmail: MAC@envisionrx.comPharmacy Audits and Fraud,Waste, and AbusePharmacy Help DeskOngoing audits, audit appeal, suspensionsEmail: pharmacyaudits@envisionrx.comFax: 844-236-3021Phone: 800-361-4542TTY: 711Provider Relations –CredentialingProvider Relations –ContractingBilling/payment, formulary, disputes and appeals,Member eligibility, plan benefits, Pharmacy Networkissues, and prior authorizations, dispute resolution,coverage determinationsPharmacy enrollment, credentialing, and change ofownershipPharmacy contracting, contract status, AWP drugpricing questionsEmail: providerenrollment@envisionrx.comEmail: pharmacycontracting@envisionrx.comNETWORK ENROLLMENT FORM AND CREDENTIALING GUIDELINESEnvisionRx utilizes NCPDP Part I and II as the source for credentialing information and documents in addition to thePharmacy Network Enrollment Request form. Pharmacies are required to maintain Part I and II of their NCPDPprofile with current and accurate information. If there are any discrepancies discovered with the information providedon the Pharmacy Network Enrollment Request form or the Pharmacy’s NCPDP profile that the Pharmacy and anyother facilities under the same ownership, may be denied, terminated, or suspended from access to the EnvisionRxNetwork and may be subject to an audit as outlined in 42 C.F.R. § 423.504.APPLYING FOR P ARTICIPATIONTo apply to become a Pharmacy in our Network, please fill out the Pharmacy Network Enrollment Request formlocated on our website and ensure Part I and II of your pharmacy’s NCPDP profile is complete and accurate. Once5

the completed Pharmacy Network Enrollment Request form is received, Provider Relations will review in addition toPart I and II of your pharmacy’s NCPDP profile.CREDENTIALING G UIDELINESEnvisionRx credentials and continually monitors the credentials of participating Pharmacies prior to and after inclusioninto the EnvisionRx Network. Pharmacies are required to meet conditions of participation set forth by EnvisionRx andadhere to governmental regulations and standards. EnvisionRx uses primary-source verification during its review ofthe pharmacy license and DEA registration. The credentialing process includes, but is not limited to, a review of thefollowing:1. Minimum Credentialing Requirements for Independent Pharmacies: Current DEA Current State License(s) Current Professional Liability Insurance of 1,000,000 per occurrence/ 3,000,000 aggregate or anequivalent Umbrella policy No sanctions per the Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE) No sanctions per any Office of Medicaid Inspector General in any state No sanctions per the General Service Administration’s (GSA) System for Award Management (SAM) Additional information as determined by EnvisionRx2. PSAOs and Chains must attest to, and be able to provide for all or a sample of pharmacies uponentrance and when requested: Verification of credentialing program for itself and each of its member pharmacies Copy of credentialing policy for itself and each of its member pharmacies All requirements listed above in number 1 If PSAO cannot attest, each Pharmacy will be recognized as an Independent Pharmacy and will adhereto the same credentialing standards as an Independent Pharmacy (see above for IndependentCredentialing Standards)QUARTERLY PROVIDER CREDENTIALING AUDITSEnvisionRx audits the credentials of its Pharmacies on a quarterly basis. We may contact your Pharmacy to requestproof of insurance coverage or additional copies of your Pharmacy’s other credentia

Envision Rx will not approve any advertisement or promotional materials that is designed to waive or discount participant Cost Share (copayments, coinsurances or deductibles). The Pharmacy will immediately discontinue use of approved advertisement, promotion or otherw