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Revised January, 2010 CONFIDENTIAL AND PROPRIETARY - page 5 / 31

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CONFIDENTIAL AND PROPRIETARY

Figure 1. Walgreens Health Initiatives’ Identification Card

Cardholder’s Name The subscriber name associated with the cardholder’s ID number. Cardholder’s ID Number The subscriber identification number. This will usually be either a nine-digit number, or nine-digit number with a two-digit suffix, or other alpha-numeric variation. (The patient’s birth date must also be submitted with claim.) Group Number A six-digit numeric code assigned to the plan must be submitted with each claim.

Please note the processing information for the plan above: BIN: 603286 PCN: 01410000

BIN:

610652

PCN:

82266461

RX Group:

586461

Value Discount Card Network ONLY:

Formulary Changes

Please refer to your Pharmacy Network Agreement with Walgreens Health Initiatives for specific requirements regarding compliance with WHI or a plan sponsor’s formulary and related WHI programs. For information regarding formulary changes, including but not limited to removal of a covered drug from a formulary or changes to the preferred or tiered cost-sharing status of a covered drug, please refer to WHI’s website or, as applicable, the website of the plan sponsor. Notwithstanding the foregoing, immediate removal of a drug deemed unsafe by the Food and Drug Administration (FDA) or removed from the market by the manufacturer may be necessary.

Walgreens Health Initiatives – Pharmacy Manual

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