EXHIBIT B
TO
AGREEMENT WITH
City of Nashua
ILLUSTRATIVE LIST OF INFORMATION
REQUIRED FROM
PHARMACY BENEFIT MANAGERS
(Non-Exhaustive)
CATEGORY a ] TYPE
Billing Transactions Patient Gender
Prescribe ID Qualifier
Prescribe ID
Patient Date of Birth
Product ID National Drug Code
Compound Code
Quantity Dispensed
Days Supply
Fill Number
Product Strength
Dosage Form
Response Transactions Date of Service Service
Provider ID Prescription
Number Ingredient Cost
Paid Dispensing Fee
Paid Sales Tax (if
applicable) Patient Pay
Amount Billing
Pharmacy NPI
CMS Data Elements Identifiers | Contract Number
Plan Benefit Package (PBP) ID
Health Insurance Claim Number (HIC#)
Indicators Drug Coverage Status
Adjustment/Deletion Flag
Out of Network Flag
Catastrophic Coverage Flag
Dispense as Written
Cost/Payment Fields Gross Drug Cost Below Catastrophic Cap
Gross Drug Cost Above Catastrophic Cap
Low-Income Cost-Sharing Subsidy Amount (LICS)
Secondary/Other Payer Amount
Supplemental Cost Share Amount
City of Nashua ll SA Revised March 2016
