NCPDP VERSION D.Ø PAYER SHEET B1, B2 Transactions **GENERAL INFORMATION** Switch: RelayHealth/NDC/McKesson ** TRANSACTIONS SUPPORTED **

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1 PAL Payer Sheet B1, B2, E1 Transactions NCPDP VESION D.Ø PAYE SHEET B1, B2 Transactions **GENEAL INFOATION** Payer Name: PAL Processing Effective as of: 1Ø/1/2Ø13 BIN: Ø15418 Date: 9/3Ø/2Ø13 Format: NCPDP Version D.Ø Switch: elayhealth/ndc/ckesson ** TAACTIO SUPPOTED ** Transaction Code Transaction Name B1 Billing B2 eversal E1 Eligibility Verification LEGEND: - andatory, - equired By Payer, W - equired When, N - Not equired, - Not Supported BILLING TAACTION: Transaction Header Segment: andatory Field # NCPDP Field Name/length Value //W/ Comment 1Ø1-A1 BIN Number Ø Ø2-A2 Version/elease Number DØ 1Ø3-A3 Transaction Code B1 = Billing 1Ø4-A4 Processor Control Number Varies by Plan 1Ø9-A9 Transaction Count 1=One Occurrence Batch transactions currently not supported 2Ø2-B2 Service Provider ID Qualifier Ø1 NPI 2Ø1-B1 Service Provider ID NPI 4Ø1-D1 Date of Service CCYYDD 11Ø-AK Software Vendor/Certification ID ØØØØØØØØØØ (zeros) or current certification number All zeros or use current switch s requirements Patient Segment: equired Field NCPDP Field Name Value //W/ Comment 111-A Segment Identification Ø1 Patient Segment 331-CX Patient ID Qualifier N 332-CY Patient ID N 3Ø4-C4 Date of Birth CCYYDD 3Ø5-C5 Patient Gender Code 1=ale 2=Female 31Ø-CA Patient First Name 311-CB Patient Last Name 322-C Patient Street Address W equired for workers compensation claims 323-CN Patient City Address W equired for workers compensation claims 324-CO Patient State/Province Address W equired for workers Page: 1 of 9

2 PAL Payer Sheet B1, B2, E1 Transactions compensation claims 325-CP Patient Zip/POSTAL Zone W equired for workers compensation claims 326-CQ Patient Phone Number N 3Ø7-C7 Patient Location N 333-CZ Employer ID 334-1C Smoker/Non-Smoker Code 335-2C Pregnancy Indicator Insurance Segment: andatory 111-A Segment Identification Ø4 Insurance Segment 3Ø2-C2 Cardholder ID 312-CC Cardholder First Name N 313-CD Cardholder Last Name N 314-CE Home Plan N 524-FO Plan ID N 3Ø9-C9 Eligibility Clarification Code N 336-8C Facility ID N 3Ø1-C1 Group ID Plan Specific 3Ø3-C3 Person Code W Varies by Plan 3Ø6-C6 Patient elationship Code 1=Cardholder 2=Spouse 3=Child 4=Other W Varies by Plan Claim Segment: andatory 111-A Segment Identification Ø7 Claim Segment 455-E Prescription/Service eference Number Qualifier 1=x Billing Also for B2 reversal 4Ø2-D2 Prescription/Service eference Number x Number assigned by pharmacy Also for B2 reversal 436-E1 Product/Service ID Qualifier Ø3=National Drug Code Also for B2 reversal 4Ø7-D7 Product/Service ID NDC Number Also for B2 reversal 456-EN Associated Prescription/Service N eference # 457-EP Associated Prescription/Service Date N 458-SE Procedure odifier Count N 459-E Procedure odifier Code Count N 442-E7 Quantity Dispensed etric Decimal Quantity 4Ø3-D3 Fill Number Ø=Original Dispensing Also for B2 reversal 1-99=efill Number 4Ø5-D5 Days Supply 4Ø6-D6 Compound Code 1=Not a compound 2=Compound Page: 2 of 9

3 PAL Payer Sheet B1, B2, E1 Transactions 4Ø8-D8 Dispense as Written (DAW) Ø=No product selection indicated 1=Physician request 2=Patient request 3=Pharmacist request 4=Generic out of stock (temp) 5=Brand used as generic 6=Override 7=Brand mandated by law 8=Generic not available in marketplace 414-DE Date Prescription Written CCYYDD 415-DF Number of efills Authorized Ø=Not Specified 1-99=number of refill N 419-DJ Prescription Origin Code Ø=Not specified 1=Written 2=Telephone 3=Electronic 4=Facsimile 5=Pharmacy 354-NX Submission Clarification Code Count W equired when submitting 42Ø-DK 42Ø-DK Submission Clarification Code ØØ=Not specified, default Ø1=No override Ø2=Other override Ø3=Vacation Supply Ø4=Lost Prescription Ø5=Therapy Change Ø6=Starter Dose Ø7=edically Necessary Ø8=Process compound for Approved Ingredients Ø9=Encounters 99=Other 46Ø-ET Quantity Prescribed Partial fills not supported 3Ø8-C8 Other Coverage Code Ø=Not Specified 1=No other Coverage Identified 2=Other coverage existspayment collected 3=Other coverage exists-this claim not covered 4=Other coverage existspayment not collected 5=anaged care plan denial 6=Other coverage exists, not a participating provider 7=Other Coverage exists-not in effect at time of service 8=Claim is a billing for a copay W equired for COB billing 429-DT Unit Dose Indicator Ø=Not specified 1=Not Unit Dose 2=anufacturer Unit Dose 3=Pharmacy Unit Dose 453-EJ Originally Prescribed Product/Service ID Qualifier 445-EA Originally Prescribed Product/Service Code 446-EB Originally Prescribed Quantity 33Ø-CW Alternate ID N 454-EK Scheduled prescription ID Number N 418-DI Level of Service 3 = Emergency N N Page: 3 of 9

4 PAL Payer Sheet B1, B2, E1 Transactions 461-EU Prior Authorization Type Code Ø=Not Specified 1=Prior Authorization 2=edical Certification 3=EPSDT (Early Periodic Screening Diagnosis Treatment) 4=Exemption from Copay 5=Exemption from X 6=Family Plan. Indic. 7=AFDC (Aid to Families with Dependent Children) 8=Payer Defined Exemption W equired when submitting 462-EV 462-EV Prior Authorization Number Submitted N 463-EW Intermediary Authorization Type ID 464-EX Intermediary Authorization ID 343-HD Dispensing Status Partial fills not supported 344-HF Quantity Intended to be Dispensed Partial fills not supported 345-HG Days Supply Intended to be Dispensed Partial fills not supported 6ØØ-28 Unit of easure N Prescriber Segment: equired 111-A Segment Identification Ø3 Prescriber Segment 466-EZ Prescriber ID Qualifier Ø1=NPI Ø6=UPIN Ø7=NCPDP Provider ID Ø8=State License 11=Federal Tax ID 12=DEA 13=State Issued ID 99=Other 411-DB Prescriber ID 467-1E Prescriber Location Code 427-D Prescriber Last Name N 498-P Prescriber Phone Number N 468-2E Primary Care Provider ID Qualifier 421-DL Primary Care Provider ID 469-H5 Primary care Provider Location Code 47Ø-4E Primary Care Provider Last Name Ø1 COB/Other Payments Segment: andatory for COB billing 111-A Segment Identification Ø5 COB/Other Payments Segment 337-4C Coordination of Benefits/Other Payments Count 338-5C Other Payer Coverage Type (epeating) 339-6C Other Payer Id Qualifier Blank=Not Specified Ø3 Ø1=National Payer ID Ø2=Health Industry Number Ø3= BIN Ø4=National Association of Insurance Commissioners (NAIC) Ø9=Coupon 99-Other 34Ø-7C Other Payer ID Page: 4 of 9

5 443-E8 Other Payer Date CCYYDD 341-HB Other Payer Amount Paid Count 342-HC Other Payer Amount Paid Qualifier Blank=Not specified Ø1=Delivery (epeating) Ø2=Shipping Ø3=Postage Ø4=Administrative Ø5=Incentive Ø6=Cognitive Service Ø7=Drug Benefit Ø8=Sum of all eimbursement 98=Coupon 99=Other 431-DV Other Payer Amount Paid 471-5E Other Payer eject Count N 472-6E Other Payer eject Code N 353-N Other Payer-Patient esponsibility Amount Count W 351-NP Other Payer-Patient esponsibility W Amount Qualifier 352-NQ Other Payer-Patient esponsibility W Amount equired when submitting 351-NP equired when submitting 352-NQ equired when submitting Other Coverage Code 8 Workers Compensation Segment: equired When Submitting a Workers Compensation Claim 111-A Segment Identification Ø6 Workers Compensation Segment 434-DY Date of Injury CCYYDD 315-CF Employer Name W Varies by Plan 316-CG Employer Street Address W Varies by Plan 317-CH Employer City Address W Varies by Plan 318-CI Employer State/Province Address W Varies by Plan 319-CJ Employer Zip/Postal Zone W Varies by Plan 32Ø-CK Employer Phone Number W Varies by Plan 321-CL Employer Contact Name W Varies by Plan 327-C Carrier ID W Varies by Plan 435-DZ Claim/eference ID DU/PPS Segment: Not equired 111-A Segment Identification Ø8 DU/PPS Segment 473-7E DU/PPS Code counter 439-E4 eason For Service Code (epeating) 44Ø-E5 Professional Service Code N 441-E6 esult of Service Code N 478-8E DU/PPS Level of Effort N 475-J9 DU Co-Agent ID Qualifier 476-H6 DU Co-Agent ID Pricing Segment: andatory 111-A Segment Identification 11 Pricing Segment 4Ø9-D9 Ingredient Cost Submitted Page: 5 of 9

6 412-DC Dispensing Fee Submitted 433-DX Patient Paid Amount Submitted N 478-H7 Other Amount Claimed Submitted Count W 479-H8 Other Amount Claimed Submitted W Qualifier 48Ø-H9 Other Amount Claimed Submitted N equired when submitting 479-H8 equired when submitting 48Ø-H9 481-HA Flat Sales Tax Amount Submitted 482-GE Percentage Sales Tax Amount Submitted 484-JE Percentage Sales Tax Basis Submitted Blank=Not specified Ø1=Gross Amount Due Ø2=Ingredient Cost Ø3=Ingredient Cost + Dispensing Fee 426-DQ Usual and Customary Charge 43Ø-DU Gross Amount Due 423-DN Basis of Cost Determination Blank=Not specified ØØ=Not specified Ø1= AWP Ø2= Local Wholesaler Ø3= Direct Ø4= EAC Ø5= Acquisition Ø6= AC Ø7= Usual & Customary Ø9= Other Compound Segment: equired When Submitting a ulti-line Compound Claim 111-A Segment Identification 1Ø Compound Segment 45Ø-EF Compound Dosage Form Description Code Ø1=Capsule Ø2=Ointment Ø3=Cream Ø4=Suppository Ø5=Powder Ø6=Emulsion Ø7=Liquid 1Ø=Tablet 11=Solution 12=Suspension 13=Lotion 14=Shampoo 15=Elixir 16=Syrup 17=Lozenge 18=Enema 451-EG Compound Dispensing Unit Form Indicator 1=Each 2=Grams 3=illiliters 447-EC Compound Ingredient Component (Count) (epeating) 488-E Compound Product ID Qualifier Ø3=National Drug Code (NDC) (epeating) 489-TE Compound Product ID (epeating) 448-ED Compound Ingredient Quantity (epeating) 449-EE Compound Ingredient Drug Cost Page: 6 of 9

7 49Ø-UE Compound Ingredient basis of Cost Determination Blank=Not specified Ø1=AWP Ø2=Local Wholesaler Ø3=Direct Ø4=EAC Ø5=Acquisition Ø6=AC Ø7=Usual & customary Ø9=Other 362-2G Compound Ingredient odifier Count 363-2H Compound Ingredient odifier Code N Prior Authorization Segment: Currently Not Supported 111-A Segment Identification 12 Prior Authorization Segment 498-PA equest Type 498-PB equest Period Date - Begin 498-PC equest Period Date - End 498-PD Basis of equest 498-PE Authorized epresentative First Name 498-PF Authorized epresentative Last Name 498-PG Authorized epresentative Street Address 498-PH Authorized epresentative City Address 498-PJ Authorized epresentative State/Province Address 498-PK Authorized epresentative Zip/Postal Code 498-PY Prior Authorization Number Assigned 5Ø3-F3 Authorization Number 498-PP Prior Authorization Supporting Documentation Clinical Segment: Varies by Plan 111-A Segment Identification 13 Clinical Segment 491-VE Diagnosis Code Count 492-WE Diagnosis Code Qualifier 424-DO Diagnosis Code 493-XE Clinical Information Counter 494-ZE easurement Date 495-H1 easurement Time 496-H2 easurement Dimension 497-H3 easurement Unit 499-H4 easurement Value Page: 7 of 9

8 EVESAL TAACTION: Transaction Header Segment: andatory Field # NCPDP Field Name/length Value //W/ Comment 1Ø1-A1 BIN Number Ø Ø2-A2 Version/elease Number DØ 1Ø3-A3 Transaction Code B2 = eversal 1Ø4-A4 Processor Control Number Varies by Plan 1Ø9-A9 Transaction Count 1=One Occurrence Batch transactions currently not supported 2Ø2-B2 Service Provider ID Qualifier Ø1 NPI 2Ø1-B1 Service Provider ID NPI 4Ø1-D1 Date of Service CCYYDD 11Ø-AK Software Vendor/Certification ID ØØØØØØØØØØ (zeros) or current certification number All zeros or use current switch s requirements Insurance Segment: Plan Specific 111-A Segment Identification Ø4 Insurance Segment 3Ø2-C2 Cardholder ID 3Ø1-C1 Group ID Claim Segment: andatory 111-A Segment Identification Ø7 Claim Segment 455-E Prescription/Service eference Number Qualifier 1=x Billing 4Ø2-D2 Prescription/Service eference Number x Number assigned by pharmacy 436-E1 Product/Service ID Qualifier Ø3=National Drug Code 4Ø7-D7 Product/Service ID NDC Number 4Ø3-D3 Fill Number Ø=Original Dispensing 1-99=efill Number Page: 8 of 9

9 ELIGIBILITY VEIFICATION TAACTION: Transaction Header Segment: andatory Field # NCPDP Field Name/length Value //W/ Comment 1Ø1-A1 BIN Number Ø Ø2-A2 Version/elease Number DØ 1Ø3-A3 Transaction Code E1 = Eligibility Verification 1Ø4-A4 Processor Control Number Varies by Plan 1Ø9-A9 Transaction Count 1=One Occurrence Batch transactions currently not supported 2Ø2-B2 Service Provider ID Qualifier Ø1 NPI 2Ø1-B1 Service Provider ID NPI 4Ø1-D1 Date of Service CCYYDD 11Ø-AK Software Vendor/Certification ID ØØØØØØØØØØ (zeros) or current certification number All zeros or use current switch s requirements Patient Segment: equired Field NCPDP Field Name Value //W/ Comment 111-A Segment Identification Ø1 Patient Segment 331-CX Patient ID Qualifier N 332-CY Patient ID N 3Ø4-C4 Date of Birth CCYYDD 3Ø5-C5 Patient Gender Code 1=ale 2=Female 31Ø-CA Patient First Name N 311-CB Patient Last Name N Insurance Segment: andatory 111-A Segment Identification Ø4 Insurance Segment 3Ø2-C2 Cardholder ID Patient SSN 312-CC Cardholder First Name N 313-CD Cardholder Last Name N 3Ø9-C9 Eligibility Clarification Code N 3Ø1-C1 Group ID Plan Specific Page: 9 of 9