Attachment 2 Medco Balance Inquiry Payer Sheet January 2010 To ...

Medco Health Solutions, Inc.100 Parsons Pond DriveFranklin Lakes, NJ 07417www.medco.com/rph1 800 922-1557Attachment 2Medco Balance Inquiry Payer Sheet January 2010To be used for non-Medicare Part D PatientsPart I - General Information:Payer Name: Medco (full name: Medco Health Solutions, Inc.) Date: 04/02/2010Processor: Medco TelePAID ® SystemSwitch:Effective as of: June 1, 2010 Information Source:Pharmacy Services Help Desk Number: 1 800 922-1557Version 5.1 Transactions supported/not supported:SupportedNot SupportedB1 Billing Transaction B3 Rebill TransactionB2 Billing Reversal C1,C2,C3 Controlled Substance ReportingN1,N2,N3 Information Reporting only supported fromthe TrOOP facilitatorP1,P2,P3,P4 Prior Authorization RequestE1Eligibility VerificationVersion 5.1 Billing Transaction Segments Mandatory/Optional/Not Supported:Mandatory/OptionalNot SupportedTransaction Header & ResponsePharmacy ProviderInsurance & ResponseWorker’s CompensationPatientPrior AuthorizationClaim & ResponseCouponPrescriberCompoundDUR/PPS & ResponsePricing & ResponseClinicalResponse Message & StatusCoordination of Benefits/Other PayerPage 1 of 9

Version 5.1 High level summary of changes:Functionality ChangesMedco will begin editing for accepted values for the Prescription Origin Code field 419-DJ for allincoming claims for new prescriptions (primary and secondary). This change will apply to anyclaim submitted with the date of service after the effective date of June 1, 2010.When the field is received with an invalid value, the claim will be rejected with NCPDP Reject Code33 (M/I Prescription Origin Code).For any new prescriptions including transfers, the accepted values are 1, 2, 3, and 4.For any refill prescriptions, including transfers, the accepted values are 0, 1, 2, 3, 4 and blank/noentry.0 is an acceptable value for refills if the pharmacy cannot determine how the physician initiallysubmitted the prescription.New BIN number 610056 for Next Generation Consumer Driven Health Program. This BIN will allow Medco toroute claims to an external host system for managing integrated Medical/RX Benefits and eligibility determination.As members move from traditional benefits to a consumer driven health program, the member may fail to showhis/her new card to the pharmacy. Therefore, in an attempt to reduce confusion, when a claim is processed to anincorrect Medco BIN number, the claim will reject with NCPDP Reject Code “01” and an additional text message to"Resubmit with BIN 610056."Claims and Reversals may only be submitted 1 transaction at a time, meaning multi-script transactions will reject.In the event that the External Vendor is unavailable or in rare instances a time out occurs, Medco will issue thefollowing NCPDP reject codes and new additional text message:- NCPDP Reject Code "92"(-Host is Unavailable) and additional text message, "Please resubmit claim in 3minutes."- NCPDP Reject Code "95"(-Time Out Waiting for Host) and additional text message, "Please resubmitclaim in 3 minutes."-NCPDP Reject Code "96"(-External Vendor has Scheduled Downtime) and additional text message,"Please resubmit claim in 3 minutes."- NCPDP Reject Code "97"(-Payer Unavailable-if claim is currently being processed and another Rx claimfor that member is submitted simultaneously) and additional text message, "Please resubmit claim in 3minutes."- NCPDP Reject Code "98"(-Communication Failure: there is a communication failure between Medco andExternal Vendor) and additional text message, "Please resubmit claim in 3 minutes."NPI, NCPDP, and Medco Pharmacy account numbers will continue to be accepted for the service provider ID unlessspecific clients require only NPI to be submitted.The DEA and state license numbers will continue to be accepted for prescribers unless specific clients require onlyNPI to be submitted.Partial fills will be supported.Compounds will be processed using highest price ingredient, compound segment is not utilized.Billing for services will be rejected.Coordination of Benefits will be supported via the COB segment only. Other coverage codes within the claimsegment are all supported with the exception of value 8 – Copay Only Billing.Patient location values for long term care should be submitted consistent with your contract in the Patient Locationfield.Patient location values for home infusion should be submitted consistent with your contract in the Patient Locationfield.Page 2 of 9

Billing Transaction (cont.):Prescriber Segment: MandatoryField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 03 M466-EZ Prescriber ID Qualifier Values 01 (NPI), 08 (State License),or M12(DEA)411-DB Prescriber ID NPI #, State License #, DEA # M427-DR Prescriber Last Name Required for State License NumberClaim Segment: MandatoryField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 07 M455-EM Prescription/Service Ref Number Qualifier 1 M4Ø2-D2 Prescription/Service Ref Number M436-E1 Product/Service ID Qualifier 03 M4Ø7-D7 Product/Service ID NDC M442-E7 Quantity Dispensed M4Ø3-D3 Fill Number M4Ø5-D5 Days Supply M4Ø6-D6 Compound Code M4Ø8-D8 DAW/Product Selection Code M414-DE Date Prescription Written M419-DJ Prescription Origin Code M42Ø-DK Submission Clarification Code M3Ø8-C8 Other Coverage Code Values 0-7 only M456-EN Associated Prescription/Service ReferencePartial FillNumber457-EP Associated Prescription/Service Date Partial Fill344-HF Quantity Intended to be Dispensed Partial Fill345-HG Days Supply Intended to be Dispensed Partial Fill343-HD Dispensing Status Partial Fill461-EU Prior Authorization Type Code Overrides462-EV Prior Authorization Number Submitted Overrides453-EJ Originally Prescribed Product/Service IDQualifier03 TherapeuticInterchange445-EA Originally Prescribed Product/Service Code NDC TherapeuticInterchange446-EB Originally Prescribed Quantity TherapeuticInterchangePage 4 of 9

Billing Transaction (cont.):Pricing Segment: MandatoryField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 11 M4Ø9-D9 Ingredient Cost Submitted M426-DQ Usual and Customary Charge M438-E3 Incentive Fee Submitted Mandatory when submitting a claim Mfor a vaccine drug and theadministrative fee481-HA Flat Sales Tax Amount Submitted M482-GE Percentage Sales Tax Amount Submitted M483-HE Percentage Sales Tax Rate Submitted When percentage tax submitted M484-JE Percentage Sales Tax Basis Submitted When percentage tax submitted M43Ø-DU Gross Amount Due Will reject if out of balance M423-DN Basis of Cost Determination MDUR/PPS Segment: OptionalField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 08 M473-7E DUR/PPS Code Counter Up to 9 occurrences M439-E4 Reason for Service Code Mandatory when submittingDUR/PPS Segment and claim isnon-vaccine.ONot required when submitting aclaim for vaccine drug and theadministrative fee.44Ø-E5 Professional Service Code Mandatory when submittingDUR/PPS Segment and claim isnon-vaccine.Value = MA (MedicationAdministered),Mandatory when submitting a claimfor vaccine drug and theadministrative fee.441-E6 Result of Service Code Mandatory when submittingDUR/PPS Segment and claim isnon-vaccine.OONot required when submitting aclaim for a vaccine drug and theadministrative fee.Page 5 of 9

Billing Transaction (cont.):COB/Other Payments Segment: OptionalField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 05 M337-4C Coordination of Benefits/Other Payments Count Up to 3 occurrences M338-5C Other Payer Coverage Type Values 01, 02, 03 only M339-6C Other Payer ID Qualifier 03–BIN or 99-Other M34Ø-7C Other Payer ID M443-E8 Other Payer Date If paid471-5E Other Payer Reject Count If rejected472-6E Other Payer Reject Code If rejected341-HB Other Payer Amount Paid Count If paid342-HC Other Payer Amount Paid Qualifier 07–Drug Benefit If paid431-DV Other Payer Amount Paid If paidClinical Segment: OptionalField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 13 M491-VE Diagnosis Code Count Up to 5 occurrences M492-WE Diagnosis Code Qualifier Value 01 only M424-DO Diagnosis Code ICD-9 M493-XE Clinical Information Counter Up to 5 occurrencesResponse Transaction:Response Header Segment: MandatoryField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional1Ø2-A2 Version/Release Number 51 M1Ø3-A3 Transaction Code B1, B2 M19-A9 Transaction Count 1 M5Ø1-F1 Header Response Status M22-B2 Service Provider ID Qualifier M2Ø1-B1 Service Provider ID M4Ø1-D1 Date of Service MResponse Message Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 20 M5Ø4-F4 Message Additional clarificationPage 6 of 9

Response Transaction (cont.):Response Insurance Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 25 M3Ø1-C1 Group ID524-FO Plan ID HRA545-2F Network Reimbursement IDResponse Status Segment: MandatoryField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 21 M112-AN Transaction Response Status P, R, D M5Ø3-F3 Authorization Number Paid claim only51Ø-FA Reject Count Up to 5 occurrences, Rejected claimsonly511-FB Reject Code Rejected claims only546-4F Reject Field Occurrence Indicator Rejected claims only547-5F Approved Message Code Count548-6F Approved Message Code526-FQ Additional Message Information Brand/generic price estimates, & TA / When HRAHRA dollars applied & remaining549-7F Help Desk Phone Number Qualifier 03, 9955-8F Help Desk Phone Number Processor, OtherResponse Claim Segment: MandatoryField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 22 M455-EM Prescription/Service Reference Number Qualifier 1 M4Ø2-D2 Prescription/Service Reference Number M551-9F Preferred Product Count Up to 5 Occurrences552-AP Preferred Product ID Qualifier 03553-AR Preferred Product ID NDC556-AU Preferred Product DescriptionPage 7 of 9

Response Transaction (cont.):Response Pricing Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 23 M5Ø5-F5 Patient Pay Amount M5Ø6-F6 Ingredient Cost Paid M5Ø7-F7 Dispensing Fee Paid M558-AW Flat Sales Tax Amount Paid559-AX Percentage Sales Tax Amount Paid56-AY Percentage Sales Tax Rate Paid561-AZ Percentage Sales Tax Basis Paid521-FL Incentive Fee Amount Paid5Ø9-F9 Total Amount Paid M522-FM Basis of Reimbursement Determination M523-FN Amount Attributed to Sales Tax512-FC Accumulated Deductible Amount513-FD Remaining Deductible Amount514-FE Remaining Benefit Amount517-FH Amount Applied to Periodic Deductible518-FI Amount of Copay/Coinsurance519-FJ Amount Attributed to Product Selection52Ø-FK Amount Exceeding Periodic Benefit Maximum566-J5 Other Amount Paid Recognized COB only346-HH Basis of Calculation – Dispensing Fee Partial Fill347-HJ Basis of Calculation – Copay Partial Fill348-HK Basis of Calculation – Flat Sales Tax Partial Fill349-HM Basis of Calculation – Percentage Sales Tax Partial FillResponse DUR/PPS Segment: OptionalField # NCPDP Field Name NCPDP Values Supported by Medco Mandatory /Optional111-AM Segment Identification 08 M567-J6 DUR/PPS Response Code Counter Up to 9 occurrences439-E4 Reason for Service Code528-FS Clinical Significance Code529-FT Other Pharmacy Indicator53Ø-FU Previous Date of Fill531-FV Quantity of Previous Fill532-FW Database Indicator544-FY DUR Free Text MessagePage 8 of 9

Reversal Transaction:Transaction Header Segment: Mandatory in all casesField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional1Ø1-A1 BIN Number 610056 M1Ø2-A2 Version/Release Number 51 M1Ø3-A3 Transaction Code B2 M1Ø4-A4 Processor Control Number Anything but zeros M1Ø9-A9 Transaction Count 1 M2Ø2-B2 Service Provider ID Qualifier Values 01 (NPI), 07 (NCPDP),Mor 99 (Medco)2Ø1-B1 Service Provider ID NPI #, NCPDP #, MEDCO # M4Ø1-D1 Date of Service M11Ø-AK Software Vendor/Certification ID Assigned when certified, claim willreject if not valid for 51MClaim Segment: MandatoryField # NCPDP Field Name NCPDP Values Supportedby MedcoMandatory /Optional111-AM Segment Identification 07 M455-EM Prescription/Service Ref Number Qualifier 1 M4Ø2-D2 Prescription/Service Ref Number M436-E1 Product/Service ID Qualifier 03 M4Ø7-D7 Product/Service ID NDC M4Ø3-D3 Fill Number M3Ø8-C8 Other Coverage Code When reversing a secondary claim Requiredwhen COBReversalPage 9 of 9