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Revised January, 2010 CONFIDENTIAL AND PROPRIETARY - page 10 / 31





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Initiatives, our system will be updated to implement the contract terms associated with such affiliation. If the NCDPD file indicates that a pharmacy is affiliated with a PSAO/TPA that is contracted with Walgreens Health Initiatives and such pharmacy also has an individual independent pharmacy network agreement with Walgreens Health Initiatives, such pharmacy’s individual pharmacy network agreement will automatically terminate unless Walgreens Health Initiatives, at its discretion, determines that an exception applies due to the need for an unique contract arrangement. Please contact us if you believe that an exception applies to your contracting arrangement.

Walgreens Health Initiatives will process all records, not identified as an exception, effective for the 1st of the following month. No affiliation letters or additional documentation will be required from you unless specifically requested from Walgreens Health Initiatives. Please NOTE: Walgreens Health Initiatives is only able to honor ONE affiliation per pharmacy.

We will still maintain the flexibility to process exceptions mid month as required for NEW pharmacies to be able to serve their patients.

Billing and Reimbursement

Prescription Claims Submission Guidelines

Pharmacies are required to submit a billing record of service for all covered prescriptions provided to a member, including those where no balance is due from the plan sponsor. Pharmacies must submit claims via electronic data interchange using NCPDP Version 5.1, as required under HIPAA. In the event of prolonged system downtime, pharmacy may submit claims within 30 days of service via either electronic transmission or 90 days of service via Universal Claim Form (UCF) or batch-file transmission.

POS System

“POS System” means the online or real time (point-of-sale) telecommunication system used to communicate information regarding covered drugs, eligible members, claims, drug utilization, copays, and/or other amounts to be collected from an eligible member by the pharmacy and the amounts payable to the pharmacy. Pharmacy Vendor and POS System: Point-of-sale claims can be submitted to Walgreens Health Initiatives through a pharmacy computer system or POS System. Please contact your pharmacy system or POS System vendor if you have any questions about how to submit claims. Phone Number: Please contact your software or communication network vendor to obtain the phone number that allows you to access the processor and submit claims. Claims Submission: Walgreens Health Initiatives will identify whether a claim has been accepted or rejected. If the claim is accepted, Walgreens Health Initiatives will identify the amount paid and the copay to collect from the member. Additionally, Walgreens Health Initiatives will provide additional messaging (e.g., quantity limitations exceeded).

Walgreens Health Initiatives – Pharmacy Manual


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