Step 3: To assist us in determining the available list of pharmacy plans to be contracted, please complete the enclosed Insurance Payer List.

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1 BillingScripts Rx Initial Enrollment Packet Thank you for choosing BillingScripts Rx for your pharmaceutical billing and funding services. This Initial Enrollment Packet contains instructions and forms necessary to get started. Please review the information in this packet thoroughly and complete the applicable forms. Upon receipt of your forms and documentation, BillingScripts Rx will prepare and then forward via , fax or U.S. Mail a Final Enrollment Packet with documentation and agreements with your information pre populated for review and authorization. Overall Steps for Initial and Final Enrollment: Step 1: Complete the Master Enrollment and Physician Enrollment Forms in its entirety and provide necessary documentation requested including making a copy of each physician s current DEA and Medical License. (Initial Enrollment Packet) Step 2: Read and completely understand the Claim Processing & Funding Overview. Review the four levels of service and benefits in the included Cost Sheet. (Initial Enrollment Packet) Step 3: To assist us in determining the available list of pharmacy plans to be contracted, please complete the enclosed Insurance Payer List. (Initial Enrollment Packet) Step 4: Fax, Scan/ or Ship Documentation plus copies of each physician s DEA and Medical license illustrated in Step 1 3 to: (Initial Enrollment Packet): Fax: enrollment@billingscriptsrx.com (Please place Practice name in Subject Line) Ship: BillingScripts Rx, LLC 1640 Akron-Peninsula Road, Suite 101, Akron, OH Attention: New Enrollment

2 Step 5: Receive pre populated forms and agreements based on your delivery preference from BillingScripts Rx. Be sure to read the instructions. Please allow up to 24 hours, upon receipt, for us to prepare your documentation. (Final Enrollment Packet) Step 6: Ship Completed Documentation to: (Final Enrollment Packet): Ship: BillingScripts Rx, LLC 1640 Akron-Peninsula Road, Suite 101, Akron, OH Attention: New Enrollment Upon receipt of your documentation, we will immediately begin to process your application. It generally can take between thirty (30) days to sixty (60) days to enroll your healthcare facility with all of the payers. Additional time may be needed for payers that you will have to contract directly to enroll. IF YOU HAVE ANY QUESTIONS PERTAINING TO THIS INITIAL ENROLLMENT PACKET, PLEASE CONTACT: TELEPHONE: Rx.com THANK YOU BillingScripts Rx Team

3 Medicare / Commercial Insurance Claim Processing & Funding Overview Credentialing, Contracting & Services In order to accept pharmacy benefits from your patients for Medicare and commercial pharmacy plans, your healthcare facility has to be specifically credentialed and contracted for pharmacy claims. BillingScripts Rx business partner is known in the pharmacy industry as a PSAO which is an acronym for Pharmacy Services Administration Organization. The PSAO handles a number of functions for our customers including: Credentialing and Contracting with Payers: The PSAO has master contracts with most pharmacy plans to accept pharmacy benefits from patients. Instead of healthcare facilities having to virtually contract with hundreds of various PBMs (pharmacy benefit management companies) and insurance companies, the PSAO has done all of the work for healthcare facilities with their master contracts. Cash Management: As funds are paid from pharmacy dispensing activities, the PSAO transfers that money into the healthcare facility s designated checking account. Reconciliation: This important service ensures healthcare facilities will be paid the correct amount contracted on all processed and paid pharmacy claims. Audit Services: From time to time, a PBM or Insurance Company could either request a desk or on site audit on a particular pharmacy claim(s). If needed, the PSAO can assist via phone, web or . Help Desk Services: If the healthcare facility is having difficulties processing a claim, the PSAO s Help Desk can assist in resolving the issue, as long as it is not related to dispensing software technical support. Contact your software provider for dispensing software technical support. Limitations The PSAO may not have contractual relationships with all PBMs and Insurance Companies that you may wish to be contracted with. The PSAO and/or BillingScripts Rx will assist you with obtaining and completing the documentation to contract with these companies directly if they allow physician pharmaceutical dispensing.

4 There are certain PBM s and Insurance Companies unwilling to credential and contract physician inoffice pharmaceutical dispensing at this time. This prevents healthcare facilities from accepting patient s pharmacy benefits from these companies, even if you are presently contracted with the same companies for your medical services. Some of these national companies include but may not be limited to Cigna, Caremark, Aetna and certain Blue Cross/Blue Shield plans. Others may include smaller regional PBM s and Insurance Companies. If you desire to accept Medicaid, not all states allow healthcare facilities to dispense pharmaceuticals to Medicaid patients. Your state s Medicaid Office will contract directly with your healthcare facility if they allow dispensing. To find out if your state s Medicaid Office allows dispensing, contact your local office. BillingScripts Rx and the PSAO will help identify which PBMs and Insurance Payers are and are not available in your service area by requesting your payer mix on the Insurance Payers List which is included in this Initial Packet. Costs BillingScripts Rx only method of payment is electronic fund transfer, also known as automatic bill pay, from one of your designated bank accounts. All charges are billed and debited from your designated bank account in advance of monthly services and collected during the first week of each month for the current month s services. The Program Startup costs will need to be paid by check with submission of your Final Enrollment Packet. The start date of your service is generally during a partial month and there will be no charge for that initial first partial month while your service is just beginning. The Annual Maintenance Fee is billed and debited thirty (30) days prior to the end of a twelve month period. See the attached Cost Sheet for more detailed information. There are certain costs associated with providing you with these services. These costs include: Startup Costs: This includes the cost for your NPDS number to electronically transmit claims across the pharmacy switch, and certain PBM / BillingScripts Rx setup costs. Monthly recurring costs: BillingScripts Rx has 4 levels of service depending on the number of claims processed per month. This flat monthly fee is all inclusive and includes the dispensing software add on module to process claims, switch fees, PSAO service fees and BillingScripts Rx fees. There are never any hidden fees. Annual Maintenance Fee: This is your renewal fee for ongoing enhancements and services.

5 Dispensing Software Your dispensing software provider has an add on module which is required to process pharmaceutical claims. Your management company or pharmaceutical repackager that provided you with the pharmaceutical dispensing software will train you on how to use this add on module and setup your system to process pharmacy claims. BillingScripts Rx generally does not offer any technical support or training on how to use your dispensing software s claim processing module or the general use of your software. Please contact your dispensing software provider for any technical assistance. Documentation This Pharmaceutical Billing & Funding Service requires the following documentation which will be provided to you for review and authorization once we receive your Initial Packet of Information: BillingScripts Rx Service Agreement and attached Cost Sheet PSAO Service Agreement HIPAA Business Associate Agreements Bank Authorization to deduct service fees and deposit paid pharmaceutical claims. Applications and Agreements with PBM and Insurance Companies that are not directly contracted with the PSAO Include checks for the startup costs Multi Locations If you have pharmaceutical dispensaries in multiple healthcare facilities, you will need to complete and authorize a separate set of documentation for each location. The costs associated with this service are per location. If you have, as an example, 3 locations, each location will be required to pay its own associated startup costs, monthly recurring costs, and annual maintenance fees.

6 General Explanation of Services Upon setup, you will be able to accept hundreds of pharmacy plans to serve many of your patients generic and brand name medication needs. Every PBM and Insurance Company determines payment based on several factors including co payment per pharmacy plan, type of medication (generic or branded) and what is the Usual and Customary Price for that particular medication to a patient that does not have pharmacy benefits also known as a self paying patient. Typically, you will receive payment based upon the lesser of either your Usual or Customary Price (Retail Price) or what the Insurance Company has determined the payment to be for that particular medication. Please consult with your Pharmaceutical Repackager or Management Company for suggestions on how to set up your Usual and Customary Price per medication and whether or not it makes sense to include branded medication in your formulary. With some generic medications, the payment amount from the PBM or insurance company could be less than the generic co payment on the patient s pharmacy plan. With other generic and branded medication, you will generally collect the co payment for that pharmacy card, which is indicated on your computer screen, with the balance paid by the pharmacy plan. It is possible, with certain generic medication, that you could potentially lose money on a dispensed bottle of medication based on what the medication cost is to the healthcare facility and what is ultimately reimbursed from the payer and co payment collected. Just keep in mind that your profit is based on all dispenses for an entire year and not a few dispenses that could potentially lose some money. In other words, overall are you making money? Most pharmacy plans do not allow reimbursement for more than a thirty (30) day supply so be aware of this when ordering medications. Thinking about stocking brands? If there is a generic equivalent available, most pharmacy plans will pay you for the generic equivalent and not reimburse for the brand, even if you dispense the brand medication. The general concept of accepting pharmacy benefits is to provide the patient with a one stop shop experience and although on occasion, certain medication could cost more money than what is collected, most medication will make money and overall the program should be profitable to your healthcare facility. It is a learning process. With this service, the software, with just several pieces of information from a patient s pharmacy or health insurance card, can process the claim electronically with no paperwork in just a few seconds. The software either lets you know that the claim is going to be paid or rejected. If it is going to be paid, the

7 software will also indicate what co payment to collect, if any, and how much money, if any, is owed to you by the pharmacy plan. The dispensing software and PSAO has available reports to provide you with your dispensing activities, profitability and accounts receivable. If a claim is rejected by a pharmacy plan, it could just be a simple fix to re process the claim for payment. Most claims submitted to contracted pharmacy plans should generally be paid without additional intervention. The PSAO provides a Help Desk to assist in determining why a claim was rejected and help with any possible solutions. Often, the problem is due to missing or incorrect information entered into the dispensing software and transmitted to the pharmacy plan. Like anything new, it takes just a little time to understand the common issues and mistakes that are made causing rejected pharmacy claims. Within a few short weeks, your pharmacy staff will become an experts. The claims information is received electronically from the pharmacy plan to the dispensing software and then on to the PSAO for tracking and remittance of payment. As the PSAO receives funds on your behalf from the pharmacy plans, they are transferred into your designated checking account daily. The copayments you collect are paid directly to you from your patients. The combination of collecting copayments, receiving funds from the PSAO and subtracting your medication cost is your Gross and Net Profit from this program. Generally, it can take 3 to 4 weeks for claims to be paid. Do you want to accept Medicaid? Medicaid is run by each state and requires a healthcare facility to be directly enrolled and contracted with Medicaid. Certain state s Medicaid Offices do not allow healthcare facilities to dispense medication for reimbursement. Please indicate on the Enrollment Form if you accept Medicaid patients. You must have a clinic group NPI number if multiple physicians will be dispensing for both Medicaid and Medicare.

8 Dispensing Location Enrollment Form Please Print Clearly All Fields Are REQUIRED Questions about this form please call or Form Prepared By : (First & Last Name) ( Address) (Phone) Facility Information PRACTICE NAME : PRACTICE TYPE: i.e. Ortho STREET ADDRESS : CITY : County : STATE : ZIP : PHONE : FAX : lity Informa OFFICE MANAGER NAME : DIRECT LINE : Regulatory and Legal Primary Doctor BUSINESS LEGAL NAME : BUSINESS TYPE Please : Sole Proprietor Corp Partnership LLC FED. TAX ID CLINIC NPI # (Diff't than Physician's) : SITE DEA # (Diff't than Physicians) : LICENSE EXPIRATION : STATE MEDICAID # : MEDICARE PART B # : NPDS NUMBER (If you already have): INSURANCE AGENCY NAME : AGENT NAME : PHONE : PROFESSIONAL LIABILITY AMOUNT PER OCCURANCE : ANNUAL : NOTE: Minimum Professional Liability should be $1 million per occurrence/claim and $3 million in annual aggregate. Please also include a legible copy of your declaration page from your commercial policy and Federal Tax ID Document THIS SECTION REQUIRES INFORMATION ON THE PHYSICIAN RECEIVING THE MEDICATION PHYSICIAN NAME : MEDICAL LICENSE NUMBER : EXPIRATION DATE : DEA NUMBER : EXPIRATION DATE : NPI NUMBER : Note: Please include a copy of physicians DEA license and Medical license. Address on DEA license must be the same address controlled medications will be shipped to. Repackagers cannot ship to any other address. Vendor Information SOFTWARE COMPANY : CONTACT PERSON : PHONE NUMBER : MANAGEMENT COMPANY : CONTACT PERSON : PHONE NUMBER : PHARMACEUTICAL REPACKAGER : CONTACT PERSON : PHONE NUMBER : AVERAGE Rx PURCHASE TOTAL / MONTHLY : $ IF KNOWN Misc. FACILITY HOURS (List days and times) : TYPE OF PATIENTS TREATED ( all that apply) : Third Party Ins. Medicare Medicaid Cash Patients Workers Comp. Personal Injury PIP / MedPay Copyright 2016 All Rights Reserved. BillingScripts Rx PLEASE FAX COMPLETED FORM TO:

9 BillingScripts Rx Physician Enrollment Form Please Print Clearly All Fields Are REQUIRED FACILITY INFO. Form Prepared By : (First name) (Last Name) ( Address) PRACTICE NAME : PRACTICE TYPE: i.e. Ortho STREET ADDRESS : CITY : County : STATE : ZIP : PHONE : FAX : lity InformaOFFICE MANAGER NAME : DIRECT LINE : PHYSICIAN NAME DEA NUMBER MEDICAL LICENSE # NPI # 1) 2) DISPENSING PHYSICIAN INFORMATION 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) YOU MUST FAX A COPY OF EACH PHYSICIAN'S DEA AND MEDICAL LICENSE THAT IS LISTED ABOVE Copyright 2016 All Rights Reserved. BillingScripts Rx PLEASE FAX COMPLETED FORM TO:

10 What s Included in the BillingScripts Rx Program? PROGRAM COSTS Contracting and credentialing with pharmacy plans Contract assistance with pharmacy plans that do not have a relationship with PSAO Cash Management Transaction Reconciliation and Reporting Audit Services (No Additional Charge for Level 4) Help Desk Support for NCPDP adjudication NCPDP Dispensing Software Module Switch Fees General Customer Support Term 2 year term $250 cancellation penalty if Healthcare Facility wishes to cancel prior to the 2 year term expiration. Total BillingScripts Rx Start Up Costs $750 Installation Fee $250 Security Deposit $275 NCPDP Fee (This is an enrollment fee paid to NCPDP for your NPDS Number to transmit claims) $1275 Total Fees (Deduct $275 if you already have an NPDS Number) PBM Application Fees $1250 for Express Scripts and Medco. Optional: $1200 for Medimpact (Not included unless requested) NOTE: One check for $2525 payable to BillingScripts Rx to be remitted with Final Packet to begin processing. Annual Maintenance Support Fee $350 collected annually thirty days prior to the end of a twelve month billing period Optional Services: Limited Audit: Per occurrence $75 Note: Audit services are performed over the phone and via web. Limited to BillingScripts Rx only Note: Level 4 pricing limited audits at no additional charge Method of Payment for Services ACH (Automatic Bill Pay). Payment is always made in advance for service. Payment is automatically debited from Customer s bank account between the 1 st and 5 th of every month for that month s service. No monthly charge for the first partial month of service.

11 BillingScripts Rx 4 Support Levels of Service: Level 1: Rx claims per month including reversals $229 per month Level 2: Rx claims per month including reversals $359 per month Level 3: Rx claims per month including reversals $499 per month Level 4: Rx claims per month including reversals $699 per month Additional Claims Over 1500 claims 20 cents per claim Monthly Costs The monthly cost for services (Levels 1 4) charged to the Healthcare Facility can change from month to month depending upon the number of claims processed in the prior month based upon the levels above. Each site automatically starts at Level 1. Thereafter, your Level will be adjusted relative to the number of claims processed. Level Increases and Decreases The first partial month is not charged to the Healthcare Facility. At the end of the first full month of service, the Level of service will automatically be adjusted every month to either a higher or lower Level of service based upon the number of claims transmitted including reversals during a previous month. Example: If a site starts off at Level 1 and in month three exceeds 250 claims by 75 claims, the site will automatically be raised to Level 2 the following month. The difference in cost that should have been collected for the higher Level for the previous month will also be collected with the following month s charges. If the site has a decrease in the number of claims for a particular month, the Level for the following month will be adjusted accordingly and the site will alternatively be provided a credit for that previous month s Level equal to the difference in cost for the lower level of service for the following month.