Plan Lists. Help Desk/ Notes. Plan Name / Network Name. AmeriHealth Mercy Health Plan, Inc

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1 Name 4D Pharmacy Mangement Systems, Inc. 4D Pharmacy Mangement Systems, Inc. 4D Pharmacy Mangement Systems, Inc. 4D Pharmacy Mangement Systems, Inc. 4D Pharmacy Mangement Systems, Inc. or Preferred-Choice Pharmacy Discount Drug Card Traditional Pharmacy Managed Choice Pharmacy Managed Pharmacy PCN: PCN: PCN: PCN: PCN: Agelity, Inc. Pre Scripts BIN: Agelity, Inc. Agelity, Inc. Agelity Prescription Benefit Plan Agelity Prescription Drug Savings BIN: BIN: Agelity, Inc. My Prescription Card BIN: Agelity, Inc. Goldline BIN: Agelity, Inc. SMCRx BIN: Agelity, Inc. Agelity Affinity Cash Discount Card BIN: PCN: 3A Agelity, Inc. Scripts BIN: Agelity, Inc. American Health Care Administrative Services, Inc. American Health Care Administrative Services, Inc. American Health Care Administrative Services, Inc. American Health Care Administrative Services, Inc. Americhoice NJ Americhoice NJ AmeriHealth Mercy Health Plan, Inc. AmeriHealth Mercy Health Plan, Inc. PPSC Cash Cash Discount Card BIN: PCN: SG BIN: AHC Citizens Health BIN: Citizens Choice HealthPlan Rx Medicare Medicaid Keystone Mercy Health Plan Retail BIN: BIN: PCN: AHC BIN: PCN: 9999 AMCNJ BIN: PCN: 2300 PCN: MAPD: All s: Name AmeriHealth Mercy Health Plan, Inc. or OTC Medications and Supplies AmeriScript, Inc. Retail Applied Underwriters, Inc. Applied Workers' Compensation Applied Underwriters, Inc. The Applied ANA day at Retail ANA - 92 Open BIN: PCN: AMER9999 BIN: PCN: APP BIN: PCN: APP Option Option 5 90 days Retail LTC ANA - 91 Priority Health Argus Home Infusion ANA - Nursing Home, Long Term Care And Assisted Living ANA - Hospice ANA ANA ANA Vrx: Deseret Mutual Administration MedicisRx ANA - 54 Discount Card ANA - 22 Health Partners of PA BIN: PCN: PCN: GRP: PCN: Retail BIN: Gateway Health Plan ANA Uninsured Member s ANA - 69 Medicare Part D Commercial PCN: Medicare BIN: PCN: Med Part D: Medicaid:

2 Name Atlantic Prescription Services Atlantic Prescription Services BC/BS of Alabama BC/BS of Alabama BC/BS of Arizona BC/BS of Arizona or ANA - 98 Part D ANA - 87 Comp-Med ANA - 98 Medicare Part D Managed Care Discount Rx Card BCBSAL Retail Specialty Pharmacy Medication BCBSAL Medicare Products Pharmacy BCBSAZ In Arizona BCBSAZ Out of Arizona BIN: Now handles all BSCA as Well BIN: BIN: BIN: PCN: BAZ, TQC BIN: PCN: BAZ, TQC Medicare: Commercial : Benescript Benescript Retail BIN: Beyond Rx Beyond Rx Beyond Rx Beyond Rx Beyond Rx Bio Scrip Bio Scrip Bio Scrip Beyond Rx Beyond Rx BRX Choice Beyond Rx VPN Beyond Rx Select II Beyond Rx Select BioScrip Medicaid BioScrip Affinity BioScrip Open Pharmacy Bio Scrip Medicaid Total Care LTC BIN: PCN: PB BIN: PCN: PB BIN: PCN: PB BIN: PCN: PB BIN: PCN: PB BIN: BIN: BIN: BIN: PCN: CLAIMNE Name or RxAmerica Zenith Insurance Company CareComp State of TN Extended Day Supply CareValue3a CareValue3b Retail 1 Retail 2 Horizon BCBSNJ RxClusive Consumer Card Savings PatientChoice 90 PreferredChoice Retail Extended Days Supply BCBS RI Influenza Administration Medicaid NY Presbyterian System SelectHealth Medicaid MetroPlus Health Plan KY BIN: PCN: STNRX BIN: BIN: Medicaid Fidelis Care Medicaid CDPHP Medicaid Affinity Health Plan BIN: Group: RX8579 BIN: Group: RXMPHP BIN: Groups: RX6460, RX6461, RX6462, RX6465, RX6466 BIN: Group: RXCDPHP BIN: Group: RX

3 Name or Medicaid Amerigroup FEP Administration Administration Coventry GHP Plans Retail Maintenance Provider 2 Molina Healthcare of Ohio Coventry GHP Plans Retail Maintenance Provider 1 BIN: Group: RX4293 BIN: , Carrier-Group: BIN: PCN: 6000 BIN: PCN: N/A Group: N/A Medicaid BIN: PCN: Eligibility and Prior Authorization Rrequests: Non-clinical or technical: CarePremier BIN: Managed Cash Orange Count MSI Retail 90 A Retail 90 B BCBS Association Provider AMERIGROUP Corporate - Florida Plan CareSelect MetroPlus Health Plan (PCS Health Systems) (PCS Health Systems) (PCS Health Systems) PCS RECAP PCS Plan Sponsor FL BIN: , PCN: CRMPT BIN: GRP: RXMPHP FEP Medicaid: PCS BIN: Retail Name or Medicaid WellCare Health Plans IPA Managed Care Organizations Sound Health & Wellness Retiree Trust Group: , BIN: Health Alliance BIN: WellCare of Kentucky Medicaid Standard Upper Peninsula Health Plan Plus HMO SNP KY WellCare of New York Sound Health & Wellness Trust WellCare of Ohio Wellcare 90 Day at Retail GRP: Part D - BIN: PCN: CLAIMCR GRP: UPHPMEDD Part B - Call Group: Family Health Plus, Healthy Choice Group: CIGNA CIGNA Specialty CIGNA CIGNA Pharmaceutical Services CIGNA CIGNA Med Part D CIGNA CIGNA LTC, DER Requests: Part D: Part B: DER Requests: Remittance Questions: DME Supply Questions: DER: Remittance: Community Care Rx-MTM MemberHealth LTC Community Care Rx-MTM CMTM Level 1 CPT Code 0115T Community Care Rx-MTM CMTM Services Declined

4 Name or Community Care Rx-MTM CMTM WMR Tasks Community Care Rx-MTM MemberHealth al A Community Care Rx-MTM MemberHealth B Community Care Rx-MTM CMTM Level 2 Community Plus Pharmacy - BCBSMS - Advanced Health Systems Cypress Care (Healthcare ) Community Plus Healthcare Workers Comp DataRx DataRx Open Emdeon Emdeon Emdeon Emdeon MedE Workers Compensation MedE Therapy First Plus MedE Preferred MedE Patient Choice BIN for NDC: BIN for Envoy: BIN: PCN: CC BIN: , , , or PCN: DRX CPT Code 0115T T or BIN: Emdeon MedE Self-Pay Emdeon MedE Therapy First Emdeon MedE Employee Health Ins Mgmt - EHIM Employee Health Ins Mgmt - EHIM EHIM LTC Pharmacy BIN: PCN: CN BIN: PCN: 54 BIN: PCN: CN BIN: , PCN: 3A, CAT, 96 BIN: PCN: CN BIN: PCN: 54 BIN: EHIM Retail BIN: Envision Elderplan Envision Fringe Benefit Management Company Ohio's Best Rx IL,, NE, NH, ME, KY, BIN: PCN: PARTD BIN: PCN: ROIRX BIN: PCN: ROIRX Name or Envision Managed HealthCare Services Company Quality Health Plans Envision LA Rx Presciption Savings Card Envision Flu & Pneumonia Envision Preferred HI Envision Preferred LTC Envision HPP Private Label Savings Card Envision LTC Envision Preferred BIN: PCN: ROIRX BIN: PCN: PARTD BIN: PCN: ROIRX Express Scripts, Inc. EN40 Express Scripts, Inc. Express Scripts, Inc. Express Scripts, Inc. Express Scripts, Inc. ESI Med Part D Administration ESI Retail TRICARE Vaccination ESI Administration Express Scripts, Inc. BCBSLA Vaccination Express Scripts, Inc. ExpressComp Express Scripts, Inc. EN50 Express Scripts, Inc. Medicaid Amida Care BIN: PCN: PARTD BIN: PCN: PARTD BIN: PCN: ROIRX BIN: PCN: PARTD BIN: PCN: PARTD PCN: A4, SC (only Med D) PCN: MD, SC (only Med D) PCN: MD, SC (only Med D) OCBL A4, SC (Med D only), PCN: A4, SC (only Med D) PCN: A4, SC (only Med D) PCN: A4 Group: KJFA

5 Name or Express Scripts, Inc. Medicaid Healthfirst Express Scripts, Inc. Express Scripts, Inc. Medicaid HIP Health Plan of New York Emblem Health Medicaid Neighborhood Health Providers PCN: A4 Group: HEFA BIN: PCN: PCN: A4 Group: KJBA First Health PRIMExtra BIN: First Health EPIC American Indian Health BIN: First Health ALTA Rx BIN: First Health First Health FLRx FLRx FLRx FutureScripts FutureScripts General Prescription Medicare Drug Discount Card EPIC NY State Senior Prescription Plan FLRx Simply Prescriptions Medicare Part D Pharmacy FLRx Simply Prescriptions Medicare Retail for Specialty Drugs FLRx Pharmacy FutureScripts Medicare Part D FutureScripts Commercial GPP s MI, MO, NY, PA BIN: BIN: BIN: BIN: Worker's Compensation Rx Discount 90 Day - FUNDED Business BIN: Name or 90 Day Supply - 100% Cash Business s RURAL RURAL 90 Day Supply Prescription Discount Card Pharmacy must reside at least 10 miles from a major metropolitan city. Pharmacy must reside at least ten miles from a major metropolitan city. LTC UNA Cash Discount Kaiser Permenente BIN: PCN: Gr HTAWEST01, HTAPORT01, USPG0023 BIN: , , , , , , , PCN: NWCMS 100% Cash BIN: HIP HIP LTC BIN: , HIP HIP Medicare BIN: , HIP HIP Medicare Extended Day Supply BIN: , HIP HIP Vaccination BIN: , Part B and Part D HIP HIP Commercial IdealScripts IdealScripts Retail BIN: IdealScripts IdealScripts 90 Day at Retail BIN: Independent Health Maintenance Drugs BIN: Independent Health Compounding BIN: Independent Health Medicaid Independent Health BIN: Independent Health Retail BIN: Innoviant Innoviant Part D 84- Days or Greater Supply Retail BIN: PCN:

6 Innoviant Name or 90-Day at Retail Innoviant Open Innoviant Innoviant Innoviant Innoviant Part D 1-83 Days Supply Retail Innoviant Home Infusion Cash Discount Innoviant Innoviant LTC BIN: PCN: , Wausau BIN: PCN: BIN: PCN: BIN: PCN: BIN: PCN: IPM IPM Retail BIN: IPM IPM GAP High Deductible BIN: Keystone Mercy Health Plan KMHP Retail Keystone Mercy Health Plan KMHP OTC Maxor Plus MaxorPlus Select Maxor Plus Maxor Prime Maxor Plus Maxor Maxor Plus Maxor Plus Maxor Plus Medicaid Hudson Health Plan MaxorPlus MaxorPlus Preferred BIN: PCN: BIN: , Medicaid Group: MDC, Family Health Plus Group: FHP. PCN: BIN: PCN: BIN: PCN: Maxor Plus Maxor FirstCare Medical Security Card ScriptSave Medical Security Card RxA s BIN: PCN: MSC, HDN BIN: PCN: RXA Admin LTC Excellus Retail Excellus LTC 17 Retail Name or Excellus Home Infusion Choice Home Infusion CRX 2009 Health Alliance IL PCN: Choice 90 w MAC Cash Discount CRX Cash Discount Card Medicaid HealthPlus, Medicaid Group: HCP9198, Family Health Plus Group: FHP9198 PCN: (HNY03-Health Plus NYS Medicaid) Excellus Extended Supply Retail Medicare Part D Excellus Commercial Employee Group KPS Health Plan Physicians of Douglas County Carolina Care - MedWest Hospital Apex Affinity Big Path AME Benefits Cash Discount Card LA Care Health Plan Health Plan Select Flu Influenza FirstCarolinaCare Influenza Vaccination Excellus Managed Medicaid Premier Health Plan (610475) PCN: (FLRX), (Group: EXC) PCN: PCN BIN: PCN: GRP: B PCN: PCN: PCN: Family Health Plus

7 Name or Name or Medicaid Univera Community Health PCN: AM-2 BIN: , PCN: MH HEB Kingsville Independent School District NY Medical and Surgical Supply Pharmacy Medicaid Health Plus of NY Family Health Plus TX HEB Hidalgo County TX Medtrak Services Group Health HealthPartners of Minnesota Vaccination Medtrak BIN: PCNL: B22942 Group: KGVL1 (not required) PCN: 58110, PCN: 58110, BIN: PCN: B22942 PCN: BIN: (NDC), (Envoy) PCN: (NDC), Call Envoy Health Plus of New York: Medtrak Services MedTrak 90 BIN: Medtrak Services Medtrak Services Performance 90 Pharmacy Open Pharmacy MH-5 Sponsored Discount s MH-4 Discount MemberHealth MemberHealth LTC MemberHealth Part B and Part D BIN: (NDC), (Envoy) PCN: (NDC), Call Envoy BIN: PCN: MH BIN: , PCN: MH Community Care Rx, Golden Buckeye Medicare, and Criterion Advantage: Enter "1" in the DUR/PPS Code Counter field and "MA" into the Professional Service Code field Mirixa MemberHealth Rural MemberHealth Fidelis MemberHealth MTM Services Community CCRx Welcome Mirixa CCRx MTM Mirixa Mirixa Navitus Navitus Navitus Medco SOCRxATES ESI 1:1 Pharmacy Outreach Navitus Part D Vaccination Navitus Medicare Part D Retail Retail IL Navitus 90 Day Retail Navitus Long-Term Care Navitus Retail (31-90 Day Supply) CPT Code: (Face to Face new patient), (Face to Face repeat Patient), (MTM via Phone), (Decline) Pharmacy will be paid $40.00 for each completed session with a patient. Pharmacy will be paid $60.00 for each completed session with a patient, subject to adjustment for geographical region. Initial session: $30 per care gap, follow up sessions: $15 per care gap per session, decline for patient refusal: $10 per patient, initial only Service Code: Face to Face , Phone (5-10 min): 98966, Phone (15 min) BIN: PCN: D1004 BIN: PCN: D or

8 Name or Name or Navitus Navitus Compound Drugs - Home Infusion Retail (1-30 Day Supply) Navitus TX Medicaid TX Contact DeanCare RX, for processing assistance in connection with compounds with ingredient costs exceeding $ BIN: or Navitus BadgerRx Gold BIN: Net Card Systems - Welldyne Florida Medicaid Workers Comp Preferred Select FL Retail C&O Railroad Employees Hospital Association Retail Neighborhood Health Providers 100% Discount Card Child Health Plus PCN: NMHC PCN: NMHC PCN: NMHC PCN: NMHC NPS Processing NPS Medicare Retail NPS Processing NPS Medicare LTC NPS Processing NPS Retail PCN: PCN Group: NHPLAN PCN: NMHC PCN: PCN Group: NHPLAN BIN: PCN: DNPS BIN: PCN: DNPS BIN: PCN: NPS NRx NRx Retail BIN: Ohio Best Rx Ohio's Best Rx OH Opus OPUS Retail BIN: PCN: OHS for Phy Claims, OHCP for Coupon s Option 1 Paramount Rx Paramount Rx MTM Pharmacists Mutual Employee Prescription Plan MTM CarePro Health Services MTM ChecKmeds NC MTM City of Ames, Iowa Employee Prescription Plan MTM Freedom Health Plan MTM Health Plan of San Mateo CareAdvantage Plan MTM Medica Health Plan Medicare Part D Plan MTM Medi-CareFirst BCBS Medicare Part D Plan MTM Personal Pharmacist MTM Partnership HealthPlan of CA Plan MTM Alameda Alliance for Health MTM UAHC Health Plan of Tennesee Plan MTM Optima Health Plan MTM Senior Whole Health Medicare Part D Plan Paramount Prescription Benefit Plan Paramount Prescription Drug Savings Partially Funded PharmaCare Preferred Card PCN: HWJ, HPSM, TQC PCN: AAH, TQC KY PCN: BIN: BIN: BIN: BIN: , PCN: RI, TDI-PA

9 Name or Independent - Oakland Pharmacy Non-Funded State of Connecticut Employees CT BIN: , Indemnity BIN: CLAIMSPRO Managed Care BIN: GOLD/PN2 BIN: Medicare Prescription Drug Discount Card and Transitional Assistance Specialty BIN: Pharmacy CLAIMSPRO Preferred PharmaCare Benefit Plan Wooster Comm Hosp and Schnucks Plans Funded s/ Vouchers/Patient Assistance ADULTCARE MED D PDM Discount Card s - 100% member copay, Workers' Comp PNPS TRUE RX BIN: PCN: MD2U. BIN: PCN: MD2C, BIN: PCN: MD : : : BIN: BIN: PCN: PBD09 GRP: or BIN: , , BIN: PCN: MEDDPDM GRP: BIN: , , BIN: PCN: PNPS BIN: PCN: PDMI ABC Managed Care BIN: Name Preferred Care Preferred Care Preferred Care or City of Toledo Preferred Care 90 Days at Retail Preferred Care Retail Pharmacy Preferred Care Retail Specialty PrimeStandard BCBS of TX HMO Blue BIN: PCN: TLDRX GRP: BIN: BIN: BIN: TX PrimeExtended BCBS of FL Medicare FL, CC Prime IL HMO 90-Day at Retail Prime 90-Day at Retail Extended Supply IL Prime Limited OK, NM BIN: PCN: BCTX Prime Limited BCBS TX BCBSTX - Pilgrim Pride Prime Limited Blue Select**** BCBS of FL HMO & PPO Prime BCBS TX HMO Blue FL, CC Prime TX BIN: PCN: PDPOK Prime Limited IL BCBS IL Non-HMO Prime Advantage PrimeStandard Rates PrimeStandard LTC Prime Plus BIN: Prime Commercial Prime Select

10 Name or Name or Pro Care Rx Managed Care Select BIN: , Day Supply - Exclusive Retail Pro Care Rx Services Pro Care Rx Extended Day Supply BIN: Pro Care Rx Hospice BIN: Pro Care Rx Westmoreland Coal Company Quantities for Hospice patients are generally limited to a 15 day supply. BIN: Pro Care Rx Preferred BIN: , Ramsell Public Health Plan - Independent Ramsell Public Health Plan - Independent Regence Rx California ADAP Immunization and OTC Medications BIN: PCN: ADP VPC Regence Rx Regence Retail BIN: Open Choice Plus HAS/Member Pay Prime Workers Compensation Medicare Prescription Drug Benefit for Leon Medical Center Rx dba Prescription Rx dba Prescription Rx dba Prescription Rx dba Prescription Rx dba Prescription Rx dba Prescription Unison Affiliated Health Plans 84 Day Supply or Greater Retail Medicare Long Term Care Molina Healthcare of California Ucare Medicare Advantage Peoples Health BIN: PCN: 5010, MISS-5025, AR-5024, TN5013, AR5024, MS5025, OH5026 BIN: PCN: 5001, 5031 BIN: PCN: 5029, 5030 BIN: PCN: Medicaid- 5050, 5051, 5052, Medicare: 500 N1-P and N-1 BIN: /Immunization Injection Vaccination Quality Health Plans BIN: and N1 BIN: OPTIMA BIN: PCN: 9999 FFS Medicaid Medicare MAPD: All others: Central Illinois Medicare Prescription Drug Benefit for Union Pacific Railroad Caresource Medicaid Plan Medicare Retail 1-83 Day Supply - Select Plus Retail BIN: PCN: 0797, 0798 BIN: PCN: Rx dba Prescription Rx dba Prescription Rx dba Prescription Rx dba Prescription Sav-Rx Southern California Drug Fund Employers Benefit Plan Medicaid UnitedHealthcare RxS Discount RxS Narrow BIN: PCN: 9999 GRP: RXS BIN: PCN: 9999 Group: ACUNY BIN: PCN: 9999 GRP: RXS

11 Name or Sav-Rx B - Premier BIN: Sav-Rx Script Care Script Care Script Care Script Save Script Save Advantage Pharmacy Pneumonia Vaccination SCL Prescription Drug Flu Vaccination RxA ScriptSave BIN: Script Save Immunization ScriptNet ScriptNet Retail Serve You Custom Rx Mgmt Serve You Custom Rx Mgmt Serve You Custom Rx Mgmt Serve You Custom Rx Mgmt Sierra Rx Stone River Workman's Comp Serve You 90 Day Retail Serve You Discount Card Serve You Workers Compensation Serve You Stone River W/C TennCare Ambulatory informedrx Consumer Card Retail BIN: PCN: SCI, NDC BIN: PCN: RXA, HDN BIN: PCN: MSC. GRP: 904 BIN: PCN: SNT PCN: SERVU PCN: SERVU BIN: PCN: 3WC GRP: UHS PCN: SERVU BIN: , PCN: TPS PCN: TENNCARE BIN: See card SXC Premier BIN: See Card informedrx Retail 90 Chain BIN: See card Chains with more than 50 pharmacies: Name or informedrx Retail 90 Independent and Small Chain TennCare LTC informedrx Choice 100 UFCW Local 655 informedrx Select informedrx Rural Pharmacy TennCare Compounding Health Xcellence Benefits Preferred Pharmacy IL BIN: See card PCN: TENNCARE Chains with less than 50 pharmacies and PSAOs: BIN: See card BIN: See card BIN: See card TennCare Specialty TDI Managed Care Svc Inc TDI Managed Care Svc Inc TDI Managed Care Svc Inc Health Plan of San Mateo Medi-Cal, Healthy Kids, Health Workers, and Healthy Family Health Plan of San Mateo Medicare Part D Retail Health Plan of San Mateo LTC informedrx Choice Plus 100 ChoiceAccess PreferredAccess Discount Card s Tmesys Plan # PCN: TENNCARE PCN: TENNCARE BIN: BIN: BIN: BIN: See card

12 Name or Name or Tmesys Plan # 1009 Tmesys Plan # 1055 Tmesys Plan # 2044 Tmesys Plan #1005 Tmesys Plan #1007 Universal Care US Script US Script US Script US Script Retail US Script Open and Medicare Part D HD-Rx Flu Immunization Kentucky Spirit Health Plan Medicaid Well Care Health Plans Ohio Medicaid WHI 90 Day WHI Performance B KY PCN: BIN: PCN: 10 A/N BIN: PCN: 10 A/N BIN: PCN: 10 A/N Only applicable to Group Number Tmesys Plan # 2066 Tmesys Plan # 1015 Tmesys Plan # 1021 Tmesys Plan # 1029 Total Script Nationwide BIN: PCN: TSCRIPT WHI WHI WHI Value (Discount Card) County of Volusia & Daytona Beach Plan Sheet WHI Plus WHI Palm Group IL WHI Performance A FL BIN: PCN: GRP: Group: , Wise Rx Retail BIN:

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