LeaderNET Information Digital Entry Form For your convenience, this form will be used to automatically populate repeating data elements in the following LeaderNET Enrollment Packet. For instance, once you have entered your 'Pharmacy Legal Name' on this form, anywhere that asks for this same information in the following forms will be automatically populated with what is entered here. If you are not filling out this form electronically, please disregard this page and continue to the pages below. Pharmacy Information Pharmacy Legal Name: ______________________________________________________________________________________________

Pharmacy DBA Name: ______________________________________________________________________________________________

NCPDP #: _________________________________________ NPI #: ____________________________________________ Street Address: _______________________________________________________________________________________________ City: _________________________________________ State: _____________________________________________ Zip: __________________________________________ County: __________________________________________ Telephone #: (________)________________________________ FAX #: (________)___________________________________

Web site Address: ________________________________________________________________________________________________ Pharmacy Owner Name: _______________________________________________________________________________________________ Chief Pharmacist Name: ______________________________________________________________________________________________

Federal Employer Identification Number (FEIN): ______________________________________________________________________ U.S. Drug Enforcement Agency Number (DEA): ____________________________ Expiration: ____________________________ State License Number: _______________________________________________________ Expiration: ____________________________

Applicant Information Applicant Full Name: ________________________________________________________________________________________________ Applicant Title: ________________________________________________________________________________________________

E-mail Address: ________________________________________________________________________________________________ Medicare #: _________________________________________ Expiration: _________________________________________ Medicaid #: _________________________________________ Expiration: _________________________________________ Cardinal Health Information Cardinal Health Account #: ________________________________________ Division #: _________________________________________

Enrollment Checklist for LeaderNET Brand New Store Enrollment (NCPDP number has never processed a claim)

Cardinal Health Account #: _____________________ Division: ______________________

NCPDP Number: _____________________ NPI number: ______________________

PBC Name: __________________________________________________________

Sales Support/Admin Name: __________________________________________________________

New Pharmacy Opening Date:

_______ / ________ / ________

*** Please refer to Pre-Enrollment Checklists (PBC and Pharmacy) located on the ISF portal for clarification on the below items***

Completion Checklist for “LeaderNET Enrollment Packet”

Leader Managed Care Program Participation Agreement (7 pages) [Leave copy with pharmacy for their records.

LeaderNET Participating Pharmacy Profile (6 pages) NCPCP Pharmacy Affiliation Relationship Affidavit (4 pages)

Caremark Provider Agreement w/ Schedule A, Addendum to Caremark Provider Agreement, and Agency Addendum to Caremark Provider Agreement (10 pages total) [If the authorized signer of the pharmacy’s provider enrollment has changed, please see the Caremark Authorized Signer Enrollment Process]

Schedule-2 Provider Authorization for Express Scripts (ESI) (1 page)

Medicare Part D Attestation (5 pages)

Medicare Part D Long Term Care Combo Shop Provider Agreement if applicable (3 pages)

Copy of current certificate of liability insurance evidencing coverage minimums: $1 million per occurrence and $3 million general aggregate coverage. [Pharmacy will not be enrolled without proper documentation evidencing that insurance coverage minimums are met.]

Business Associate Agreement Leader Drugstores, Inc. w/ Exhibit A (5 pages)

Central Pay Enrollment Form (1 page) [Copy of voided check must be provided.]

Reviewed “Setting Customer Expectations” form and obtained signature (1 page) [LeaderNET enrollments will not be processed without this form being signed by the sales representative.]

Completion Checklist for Documents Required

Copy of State License with updated expiration date

Copy of DEA Certificate with updated expiration date

Copy of acceptable Federal Tax ID document

Copy of PIC License with updated expiration date

Copy of NPI Confirmation Document

(Required for new startup pharmacy) Completion Checklist for Additional Important Information

Explained about enrolling directly with certain Plans/PBMs not contracted with LeaderNET (e.g. Cigna and Humana)

Provided the pharmacy with NCPDP contact number 480.477.1000

Provided the pharmacy with Caremark’s pharmacy enrollment contact number 480.391.4623.

Provided the pharmacy with Medco’s pharmacy enrollment contact number 800.922.1557.

Provide pharmacy with Post Action Items list for review

***All Enrollment forms must be sent to Sales Support (Sales Admin) for submission by noon on Wednesday***

!!!! Any and all enrollment forms sent directly to the Enrollment Team will be denied!!!!!

***Incomplete paperwork will not be submitted for enrollment***

1 April 2010

LEADER® MANAGED CARE PROGRAM PARTICIPATION AGREEMENT

Instructions to Applicant

Participation Application and Agreement

Terms and Conditions of Participation

2 April 2010

The business listed below agrees to become a Participating Pharmacy in the Leader® Managed Care Program, in accordance with the provisions of this Application and Agreement and the Terms and Conditions of Participation, which are attached to and incorporated into this Application and Agreement by this reference. The person executing this Application and Agreement on behalf of the pharmacy business listed below is authorized to execute this document, and has reviewed and, by execution of this Participation Application and Agreement, accepts the Terms and Conditions of Participation in the Leader® Managed Care Program.

PLEASE PRINT

Name of Pharmacy

Name of Pharmacist

Street Address

City, State and Zip Code County

Telephone Number (include area code) of Store

NCPDP Number

NPI Number__________________________________________________________________

U.S. Drug Enforcement Agency (DEA) Number

Federal Employer Identification Number (FEIN)

State Pharmacy License Number

ACCEPTANCE BY PHARMACY Signature Date

Name/Title

ACCEPTANCE BY LEADER DRUG STORES, INC. Date

Vice President- Managed Care

3 April 2010

TERMS AND CONDITIONS OF PARTICIPATION IN THE LEADER MANAGED CARE PROGRAM

1. The LEADER Managed Care Program. Leader Drug Stores, Inc. (“Leader”) shall solicit and use its best efforts to contract, on behalf of each participant ("Participant"), with various employers, unions, insurance companies and other groups providing pharmaceutical benefits ("Groups") to participate in the Leader Managed Care Program. Each Participant shall provide the services required by each Group contract in accordance with the other terms and conditions that follow and in accordance with written communications issued by LEADER or the Groups via email, written communications, manuals, website postings or such other means determined by LEADER or the Groups, in their respective sole discretion, and updated from time to time (such communications shall be referred to herein as the “Participant Instructions”).

2. Fees.

Upon the execution of the Participation Agreement, the Participant shall pay to Leader the amount of $200 as an enrollment fee. In addition, Leader may from time to time charge the Participants additional fees as compensation for obtaining and maintaining access to the Groups and the specific programs or services provided by Leader in connection with administering the Program. Leader will invoice the Participants for the amount of any such additional fees.

3. Patient Profiles.

Each Participant may be required to keep a patient profile on each Group's member or beneficiary. The type of patient profile is to be determined by the Participant. Upon request, each Participant may be required to provide a Group's member or beneficiary with a copy of appropriate portions of his patient profile.

4. Consumer Drug Information.

Each Participant may be required to provide each beneficiary, as appropriate, with information about each prescribed drug in a form comprehensible to the beneficiary. The type of consumer drug information will be left to the Participant.

5. Patient and Prescriber Counseling.

Each Participant may be required to provide, where appropriate, pharmacist counseling services both to Group's member or beneficiaries and to prescribers.

6. Other Services.

Each Participant may be required to provide other

services within the pharmacy's service area to any Group's beneficiary or member as required by the particular contract with that Group. For example, each Participant may be required to provide prescription drug program beneficiaries with 24-hour-a-day, seven-days-a-week emergency services (e.g., dispensing of prescription drugs after normal business hours). Unless specified in the Participant Instructions, the manner in which those services are provided is to be determined by the Participant.

7. Programs.

Each Participant may be required to participate in peer review and/or other quality assurance programs and may be required to take appropriate action in response to situations identified through the quality assurance programs.

8. Co-Pay Collection.

Each Participant is required to collect from the Group's member or beneficiary the complete amount of any co-payment which the Group contract payor requires pursuant to the contracts entered into by LEADER.

9. Claims Submission and Processing. Each Participant must submit claims using the forms

or electronic claim format as may be required by LEADER and/or the Group or Group’s processor.

10. Contracts. a. Each Participant must participate in each and every

Group contract accepted by LEADER, in accordance with the following procedures. The actual effective date of commencement or termination of each Group contract will be specified by LEADER.

b. The procedures for accepting a Group contract shall

be as follows:

1. The criteria for the acceptance of Group contracts initially has been established by the Leader Managed Care Advisory Board and representatives of LEADER. Any Group contract which, in the reasonable judgment of LEADER satisfies the established criteria will be included as part of the Program and appropriate explanations of the contract's terms and conditions will be provided to Participants in the Participant Instructions and updates thereto.

4 April 2010

2. If a proposed Group contract does not satisfy the established criteria, it will be submitted to a Contract Review Panel for advice and counsel. The Contract Review Panel will review all such contracts and decide whether they should be accepted as part of the Program. The Contract Review Panel shall be composed of two (2) representatives of the Managed Healthcare Department of Cardinal Health (or representatives of other Cardinal Health subsidiaries) and designated independent pharmacists who are members of Leader and are Participants in good standing under their program membership agreements with Leader and their Participation Agreement. Each participating member of the Contract Review Panel shall serve for a term of two (2) years from the date of his or her appointment and may be re-appointed for one (1) two (2) year consecutive additional term. Contract Review Panel members may serve for additional terms as set forth above following a break in service.

c. LEADER cannot and does not warrant or represent

that a Participant will have any particular level of profit from participation in any or all of the Group contracts.

d. The following additional terms shall apply to any

contract relating to workers compensation:

1. Participant hereby authorizes LEADER to be its attorney in fact for the purpose of entering into contracts on behalf of Participant, wherein Participant agrees to sell and assign Participant’s rights, accounts and other rights and claims to payment for certain workers compensation prescription claims submitted by Participant (the “Claims”) to a vendor designated by LEADER (the “Vendor”). The sale and assignment of such rights and claims shall apply to Claims that Participant elects to submit to the Vendor, and Participant is not obligated to submit any number of Claims, if any, to any Vendor.

2. Participant hereby authorizes the Vendor to submit such Claims for payment on its behalf to insurance carriers, self insurance plans and other account debtors and to act, to the extent necessary, as its authorized agent and attorney in fact and to undertake claims verification and processing services on its behalf and recover reasonable compensation for such services from insurance carriers, self insurance plans and other account debtors other than the Participant. The Vendor may act as an authorized agent or attorney in fact on behalf of the Participant only to the extent necessary to process the Claims, and accept, discharge, compromise, discount or

modify the obligations of insurance carriers, self insurance plans, and other account debtors to make payments for the Claims, and Vendor is not authorized to otherwise take any actions on behalf of the Participant or to otherwise bind or alter the legal relationships of the Participant with any other person.

3. Participant warrants to LEADER and Vendor that with regard to each Claim submitted and assigned to Vendor that: (i) such Claim is for bona fide prescription medications and services provided by Participant to a customer in accordance with the information set forth on the Claim; (ii) the assigned rights associated therewith are owned by and owing to Participant without dispute or any right of offset or counterclaim, and free of any liens, security interests, encumbrances or claims of third persons; (iii) the sale and assignment of the assigned rights associated therewith to Vendor does not and will not contravene any agreements to which Participant is a party with any other persons; (iv) the prescription was filled in accordance with all applicable federal and state laws and regulations; and (v) the Participant has paid or shall assume sole and exclusive responsibility for the payment of any sales taxes imposed upon medications and services provided by the Participant. Each of the foregoing warranties will survive termination or expiration of the term of this Participation Agreement, and remain in full force and effect.

e. If at any time during Participant’s participation in the Program, the total amount payable to Participant by relevant Groups through LEADER’s central payment offering is less than the aggregate amount identified by those same Groups as owed to them by Participant as the result of an audit recoupment or other reconciliation process, then , Participant shall immediately pay to LEADER or an affiliate designated by LEADER, the amount of this ”Negative Account Balance”. LEADER may, in its sole discretion, agree to finance the Negative Account Balance through an alternative arrangement.

11. Laws. a. Each Participant must comply with all applicable

state and federal laws and regulations affecting either the practice of the profession of pharmacy or the operation of a pharmacy, including but not limited to having a licensed pharmacist available during the hours of business for patient consultation and, at all times, holding a valid permit to operate a pharmacy in the jurisdiction where the Participant does business.

b. Each Participant warrants to LEADER and each

Group that it understands and complies with the

5 April 2010

requirements of the laws, regulations and guidelines created in connection with Medicare Part D, and will attest to this, as well as complete other requests for information upon request by LEADER.

12. Liability. a. Nothing contained herein shall be construed to

require the Participant to render any pharmaceutical service or dispense any prescription medication if, in the pharmacist's professional judgment, such service should not be rendered or such medication should not be dispensed. Participant must assume complete legal responsibility for liability arising out of all acts taken by its agents pursuant to contracts accepted by LEADER hereunder and agree to indemnify and to hold harmless LEADER from any liability or costs, including attorney's fees, for any such acts. Each Participant will maintain adequate professional and other appropriate liability insurance in an amount not less than $1,000,000 per occurrence and $3,000,000 in the aggregate. Failure to maintain such insurance coverage or to provide satisfactory proof of such insurance coverage may result in Participant's inability to participate in any one or all Group contracts. Such proof of insurance shall be provided to LEADER upon request in the form designated by LEADER, and a copy will be kept on file and may, upon request of any Group, be photocopied and a copy provided to such Group as proof of Participant's insurance coverage. LEADER reserves the right to increase or decrease in the future the minimum limits of liability insurance coverage required to be maintained in order to meet the requirements of any individual Group contract when it is necessary to do so, to conform to the then current standard within the industry. Each Participant shall look solely to each Group's payor for all compensation for services rendered to insurance claim beneficiaries of contracts presented by LEADER. LEADER will provide appropriate assistance to each Participant in obtaining such compensation. LEADER assumes complete legal responsibility for liability arising solely out of its acts and agrees to hold harmless Participants from such acts.

b. If any group contract accepted by LEADER should,

in any jurisdiction, violate or in its implementation cause a Participant to violate any federal, state or local law, the Participants in that jurisdiction shall not be required to participate in that particular Group contract.

13. Notification.

Each Participant must notify LEADER immediately should it cease to meet any aspect of these Terms and Conditions of Participation.

14. Termination or Rejection.

LEADER reserves the right to terminate or to reject

any pharmacy for cause from participating in the Leader Managed Care Program. Such termination or rejection shall not be limited to failure to comply with these Terms and Conditions of Participation, but shall also include a failure to comply with the terms and conditions of the Participant’s program membership agreement with Leader or the terms of any other agreement with Cardinal Health or any of it subsidiaries, and any other action of Participant that affects adversely the reputation of Leader Drug Stores, Inc., or its ability to contract with any Groups. Any challenge to such termination or rejection shall follow the grievance procedures specified in the Participant Instructions. A terminated Participant shall take all appropriate action to ensure that it is no longer identified as a Leader Participant and shall return all Leader materials in possession of such Participant to LEADER immediately upon termination. Immediately upon termination, Participant must pay LEADER, in immediately available funds an amount equal to any Negative Account Balance in effect at the time of termination.

15. New Terms/Program Termination.

LEADER reserves the right to change in writing the Terms and Conditions of Participation at any time. Participants will be provided an opportunity, in writing for response within a specified time frame, either to accept the new Terms and Conditions of Participation or to withdraw from the Leader Managed Care Program participation. If Participant does not respond within the specified time frame, Participant will be deemed to have accepted the new Terms and Conditions of Participation. LEADER reserves the right to terminate the entire Program at any time upon 90 days prior written notice to Participants.

16. Term.

The initial term of a Participant's participation in the Program shall be two (2) years from the date of acceptance into the Program by LEADER (the “Initial Term”). Thereafter, the term of participation shall renew automatically for additional one (1) year periods unless notice of termination is given by the Participant to Leader at least 120 days prior to the end of the term then in effect, in which case participation shall terminate at the end of that term. Notwithstanding the foregoing, after the expiration of a Participant’s Initial Term, that Participant will have the right to withdraw its participation from the Program for any reason whatsoever by giving Leader written notice of such withdrawal, which shall be effective 120 days following receipt by Leader of the written notice. Notwithstanding the foregoing, no termination notice shall be effective from any Participant until that Participant has paid all amounts due to Leader under these Terms and Conditions of Participation. Participant shall pay LEADER, in immediately available funds, for all

6 April 2010

amounts accrued and/or payable through the effective date of the withdrawal. For the avoidance of doubt, Negative Account Balances are included in amounts payable to LEADER.

17. Status of Parties.

Each Participant participates in the Leader Managed Care Program as an independent contractor to provide prescription drugs and other professional pharmacy services to the prescription drug beneficiaries pursuant to contracts presented by LEADER.

18. Expenses.

a. LEADER shall be authorized to pass through to Participants in each Group contract the costs for claims processing, disbursement of monies to Participants received from a Group's payor and other expenses incurred in the implementation of each Group contract on such basis as is appropriate for that contract. When necessary, LEADER is authorized to advance and be reimbursed for such costs. Other expenses can include, but are not limited to, the cost incurred for identification cards, benefit booklets and other printed materials required by the Group sponsor or administrator or necessary to implement the contract. Any such costs and expenses shall be disclosed to the Contract Review Panel and included in the explanatory information provided for each Group contact in the Participant Instructions.

b. A Participant may incur costs to participate in the

Programs for items such as on-line claim adjudication, data processing equipment, computer software licenses, telephone lines and other items.

19. Pharmacy Services.

Each Participant agrees to provide each Group's members or beneficiaries with prescription drugs and other appropriate items pursuant to the legal prescription of a licensed prescriber presented by the member or beneficiary.

20. Records.

Each Participant shall provide authorized representatives of LEADER with an opportunity to examine and audit the Participant's records pertinent to contracts presented by LEADER.

21. Notices.

All notices sent by the Participant and LEADER or representatives of either party, pursuant to the Participation Agreement, shall be sent by United States Postal Service, first class mail, postage prepaid, and addressed using the addresses provided on the Participant Application or to any updated address provided by Participant.

22. Assignment.

The Participation Agreement may not be assigned by Participant. LEADER may assign or delegate from time to time the Participation Agreement or any or all of its rights or obligations under these Terms and Conditions, the Participation Agreement or the Program to any third party (including, but not limited to, any other subsidiary or affiliate of Cardinal Health, Inc., an Ohio corporation); provided, that such third party agrees to comply with these Terms and Conditions, the Participation Agreement, and the Program.

23. Marketing.

Each Participant agrees to provide LEADER with its consent to use its name in any marketing or advertising materials developed and disseminated by LEADER that may contribute to the success of the program.

24. Grievance Procedures.

a. Participant shall look solely to each Group, Group member or other third party, as appropriate under the law and the applicable contract, for all compensation for prescriptions and other goods supplied and services rendered. Participant recognizes and agrees that LEADER is not responsible for and does not in any way warrant or guarantee payment to Participant under any Group contract. LEADER has established the following grievance procedures to assist in the resolution of disputes between the Participant and the Groups and their members. Disputes between a Participant, on the one hand, and Groups, Group members or other third parties, on the other, first shall be referred to LEADER before the Participant exercises formal legal remedies against the Groups or their members. LEADER will assist the Participant to resolve the dispute on behalf of the Participant. Representatives of LEADER will review the facts of the dispute with the Participant and the Group. LEADER will have no authority to settle or otherwise resolve any dispute on behalf of a Participant without the Participant's prior approval. If the matter cannot be resolved informally, the Participant will be entitled to exercise any right or remedy available under the contract or applicable law. LEADER will not be responsible for any legal fees, costs, expenses, liabilities or damages resulting from the dispute between the Participant and the Group, Group member or other third party. The Participant does not waive any rights available under the Group Contract or under applicable law by following these procedures. In addition to providing assistance pursuant to the foregoing grievance procedures, LEADER may provide other assistance to Participant, including assistance in obtaining compensation for prescriptions, goods and services.

7 April 2010

b. Participant agrees to accept and comply with the terms and conditions of any arbitration clause in a Group contract.

25. Agreement Administration - Participant

Instructions. LEADER may develop and set forth in Participant Instructions or other document acceptable procedures necessary of the proper administration of the Participation Application and Agreement and any and all Group contracts accepted by LEADER and each Participant shall implement these procedures.

26. Entire Agreement.

The Participation Agreement and the Participant’s cooperative advertising program membership agreement constitute the entire agreement between the Participant and LEADER; there are no other agreements or understandings with respect to this subject matter. The Participation Agreement may be modified or amended only in writing and only if signed by authorized representatives of the Participant and LEADER.

27. Non-Exclusive.

If any Participant is offered the opportunity to participate in a plan or other group benefits contract that is not part of the Program, such Participant shall promptly notify LEADER. LEADER shall review the plan and has the option to include it as part of the Program if it satisfies the established criteria or is otherwise approved by the Contract Review Panel. If LEADER elects not to include the plan as part of the Program, the Participant may then become a participant in the plan on its own. Nothing shall be construed in the Participation Agreement to prohibit either the Participant or LEADER from contracting with other parties to provide pharmacy services.

28. Mark and Logo.

By virtue of the Participant being a part of the Leader Managed Care Program, the Participant is licensed to use the service mark "Leader" in connection with advertising services as a Participant. LEADER retains full ownership rights in the mark. The Participant agrees to use the trademark only in a manner prescribed by LEADER. All such use of the mark shall inure to the benefit of LEADER. The Participant shall immediately discontinue the use of the name, symbol or service marks of LEADER upon termination, for any reason, of the Participation Agreement.

29. Ohio Law and Jurisdiction.

This Participation Agreement, the relationship between each Participant and LEADER and any dispute between our respective affiliates, officers, directors, shareholders and employees shall be

governed by the interpreted in accordance with the internal laws of the state of Ohio.

30. Participation Agreement.

To become a Participant, a duly authorized representative must execute and deliver a Participation Application and Agreement to LEADER. A copy of these Terms and Conditions of Participation should be retained. The Participation Application and Agreement shall not become effective unless and until signed and executed by a duly authorized representative of LEADER. Pharmacies in good standing under their program membership agreements may become Participants, and only those pharmacies that remain in good standing under their program membership agreements and this Agreement shall remain Participants. The pharmacy copy of the Participation Application and Agreement, upon signing by LEADER, shall be returned to and retained by the Participant.

31. Medicaid/Medicare. If and to the extent any discounted prices, credits, or

rebates are earned and paid by LEADER with respect to any of the transactions described herein, then applicable provisions of the Medicare/Medicaid and state health care fraud and abuse/anti-kickback laws (collectively, “fraud and abuse laws”) may require disclosure of the applicable price reduction on Participant’s claim or cost reports for reimbursement from governmental or other third parties. Participants shall comply with all applicable provisions of the fraud and abuse laws and agree to indemnify and hold LEADER harmless for any failure on their part to do so.

32. Other Participants.

Other Non-Leader pharmacies may be invited to become participants for a particular Group Contract if necessary under the terms established by the Group sponsor or administrator to effectively serve the Group’s members and beneficiaries. Such Non-Leader pharmacies will execute a separate agreement limited to participation in such Group Contract

1. If you have three or more pharmacies being covered by this contract, do you have a

NCPDP chain code? If yes, please list chain code(s): �Yes � No

2. Is this pharmacy an open-door pharmacy where you fill prescriptions for all walk-in customers without restrictions?

�Yes � No

3. Do you maintain patient profiles? If yes, are they electronic?�

�Yes � No �Yes � No

4. Do you review prescriptions dispensed for drug interactions? �Yes � No 5. Is this pharmacy equipped to submit claims electronically in the most current NCPDP

format? If no, please explain: �Yes � No

6. Are you affiliated with a buying group or Co-op? If so, please list name: �Yes � No

7. Do you provide any special services or have distribution rights to any specialty medications? If yes, please attach detail.

�Yes � No

8. Has your pharmacy or another pharmacy you have owned ever received less than satisfactory rating by the State Board of Pharmacy, ever had its license or registration suspended/revoked or any other action taken against it? If yes, attach explanation.

�Yes � No

9. Have any of your pharmacists ever been disciplined by the State Board, the State or Federal DEA or the State Medicaid Department? If yes, attach explanation.

�Yes � No

10. Has the pharmacy, under current ownership, or any of its currently employed pharmacists ever been the subject of a civil lawsuit or criminal prosecution for fraud, deceit, deception or a similar offense involving moral turpitude? If yes, attach explanation.

�Yes � No

11. Has the pharmacy, under current ownership, or any of its principals ever filed for bankruptcy, reorganization, or made a general assignment in favor of creditors? If yes, attach explanation.

�Yes � No

12. Has the Pharmacy or any of its principals or pharmacists, ever been suspended or excluded by the Office of Inspector General (OIG) from participating in any federal or state health care program (e.g., Medicare, Medicaid, CHAMPUS) or by the General Services Administration (GSA) from participating in any government contract/services. If yes, attach explanation.

�Yes � No

13. Is there any pharmacist(s) on staff that would NOT be covered by malpractice insurance coverage?

�Yes � No

14. Has the Pharmacy ever changed names? If yes, when? . If yes, attach a list of the previous name(s).

�Yes � No

15. Has the Pharmacy ever undergone a change in ownership? If yes, when? . Please attach a list of the previous owner’s name(s).

�Yes � No

16. Is the Pharmacy a Medicare Part B Provider? If yes, please provide this Pharmacy’s Part B Provider Number: _______________________

�Yes � No

17. Is this pharmacy affiliated with any other pharmacy or entity, which presently maintains a pharmacy agreement with ESI? If yes, please list.

�Yes � No

18. Has this Pharmacy participated in an Express Scripts, Inc. network before? If yes, when and under what name(s)?

�Yes � No

19. Have any of the owners, officers or directors of the Pharmacy owned any other pharmacy that has participated in an Express Scripts, Inc. network? If yes, please attach a list of the pharmacies and the names of the owners, officers and directors.

�Yes � No

Store Information Is your pharmacy affiliated with any other PSAO(s) (Pharmacy Services Administrative Organizations)? □ Yes □ No If yes: Termination Date: ____________________________

Name of PSAO(s): □ United □ Access □ Good Neighbor □ Northeast Pharmacy Services Other: ______________________________________ Are you a member of a Buying Group? □ Yes □ No If yes, Name of Buying Groups(s): □ API □ ANP □ Northeast Pharmacy Services Other: ______________________________________ Pharmacy Dispenser Class: □ Franchise □ Clinic □ Hospital □ Chain □ Government/Federal □ Independent/Retail Please Describe Your Type of Pharmacy: □ Apothecary □ Grocery □ Home Fusion □ Long Term Care Provider □ Clinic Pharmacy □ Full Line □ Closed Door □ Nursing Home Provider □ Chain Drug Store □ Tribal □ Union □ 340B □ Non Union □ Department Store □ Institution □ Mail Order □ IVTx □ Other: ____________________________ Staff Information Pharmacist: ____________________________ License/DEA#’s: _________________________________ Pharmacist: ____________________________ License/DEA#’s: _________________________________ Pharmacy Tech: _________________________ CPhT #: _______________________________________ Pharmacy Tech: _________________________ CPhT#: ________________________________________

LeaderNet© Help Desk: 888.887.5323 LeaderNET© Participant Manual A.16

SERVICES From the list below, please indicate which services are provided by your pharmacy: Extra Charge □ Blood Pressure Machine □ □ Brown Bag Program □ □ Compliance Program □ □ Compounding □ □ Sterile Hood □ Delivery □ □ Drug Interaction Monitoring □ □ Durable Medical Equipment □ □ Full Line □ Limited □ Emergency after-hours □ From the list below, please indicate which services are provided by your pharmacy: Extra Charge □ Health Care Screenings □ □ Medical Literature □ □ Patient Counseling □ □ Refill Reminder Program □ □ Special Packaging □ □ Special Education Leaflets (provide sample) □ From the list below, please indicate which reference books are available at your pharmacy: □ Facts and Comparisons □ United States Pharmacopoeia Dispensing Information □ Remington’s Pharmaceutical Sciences □ FDA – Approved Drug Products with Therapeutic Equivalence Evaluations □ Hastens Drug Interactions and/or Drug Interactions Facts From the list below, please indicate which features apply to your pharmacy: □ Drive-up Window □ Handicap Access □ Employee Handbook □ Policy and Procedures Manual □ Rx Error Procedures (written policy) □ HIPAA Privacy & Security Guidelines □ Pharmacy Intervention Documentation System Please specify which system: ___________________________________________ □ Patient Consultation Area: □ Semi-Private □ Private □ Other, please explain: _______________________________________________________

LeaderNet© Help Desk: 888.887.5323 LeaderNET© Participant Manual A.17

How many miles is the closest retail pharmacy to your location? □ 0-5 □ 6-10 □ 11-20 □ Over 20 Is your pharmacy a 24 Hour location? □ Yes □ No If no, how many hours is your location open per week? ______________ Pharmacy Hours:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

to to to to to to to Approximate size (sq. ft.) of pharmacy: ____________________________ Number of prescriptions filled per day: □ Brand New Store □ Under 100 □ 100-150 □ 151-200 □ Over 200 Computer Software Vendor: _____________________________________________________ Switch: □ NDC □ Envoy □ ScriptLINE □ Other: _______________ Do your pharmacists and/or staff speak any other languages? □ Spanish □ Pharsi □ French □ Arabic □ Italian □ Vietnamese □ Yiddish □ Greek □ Russian □ Polish □ Korean □ Persian □ Hindi □ German (Deutsch) □ Other: __________________

LeaderNet© Help Desk: 888.887.5323 LeaderNET© Participant Manual A.18

SPECIALTY PROGRAMS From the list below, please indicate which patient care/disease management services are offered by you pharmacy: □ AIDS □ Asthma

□ Diabetes □ Gastrointestinal

□ Home Infusion □ Hospice

□ Hyperlipidemia □ Hypertension

□ Immunizations □ Nutrition

Pharmacy is certified? □ Yes – Agency and Number ______________________

□ No, not required □ Long Term Care □ Respiratory

□ Smoking Cessation □ Thyroid

□ Other (please specify):__________________________________________________

Are you certified for any of these services? □ Yes □ No If yes, please indicate which service and by which organization: ________________________________________________________________ ________________________________________________________________ INSURANCE INFORMATION IMPORTANT NOTE:

$1 million/$3 million minimums.

Copy of current certificate of insurance MUST be submitted with “Participating Pharmacy Profile” form (see sample). ENROLLMENT PROCESSING CANNOT PROCEED WITHOUT COPY OF CURRENT CERTIFICATE. LeaderNET will accept a copy of an umbrella policy provided that the amount of coverage meets or exceeds the

Pharmacy Affiliation Relationship Affidavit NCPDP 03/2011 Page 1

The National Council for Prescription Drug Programs (NCPDP) maintains the NCPDP

Pharmacy Database, which contains information on pharmacy demographics, hours of operation, licensing information, pharmacy payment center information, remit and reconciliation information, and other relationships and affiliations including your relationships with other entities. Industry uses this database for claims processing, direct mailings of product recalls and publications, network development, health plan directories and rebate information.

The lack of a standardized form has led to confusion and ultimately, to the occasional

disruption of proper payment and claims processing at the pharmacy level. Therefore, NCPDP has developed a universal relationship form for PSAO’s in order to standardize the industry.

Form Information

Please complete all sections of the form. Bold and underlined

fields are required, and the form will not be processed if any required field is left blank.

Forms must be received within 30 days of the signature date on the form in order to be processed. Section 1 requires information about the pharmacy. All bold and underlined

fields are required to process the form.

• Section 2 is for establishing and reporting active relationships. All active Chain, Franchise or Third Party relationships should be listed, as well as any relationships that you are beginning. PSAO must pre-populate Section 2 before sending this form to the pharmacy. If you establish a new, exclusive Third Party relationship in this section, any Third Party affiliations you had for the same Provider Types prior to this establishment will be terminated. If you are unsure of your relationship, payment center or Provider Types, please contact your PSAO directly.

• Section 3 is for ending relationships. Any and all relationships that are no longer active should be listed. If you are establishing a new, exclusive Third Party Relationship, please list any terminating relationships you had prior to the new exclusive Third Party Relationship for the same Provider Type in order to terminate them. If you are unsure of your relationship, payment center or remit and reconciliation codes, please contact your PSAO directly.

• Section 4 is the Authorization section. The signature of your pharmacy’s authorized

representative and the date are required in order for the form to be processed. The date in this section must be within 30 days of the received date for NCPDP to process the form.

If you have any questions regarding this form, please contact your PSAO to assist you.

Pharmacy Affiliation Relationship Affidavit NCPDP 03/2011 Page 2

This Affidavit is to affirm my pharmacy’s affiliation relationship(s) as documented below. I understand my pharmacy’s relationships will be updated on the National Council for Prescription Drug Programs (NCPDP) Database if received by NCPDP within 30 days of the signature date on this form and will be based on the Effective Date(s) indicated below.

All fields in bold and underlined

font must be filled out in order for form to be processed.

SECTION 1 – PHARMACY INFORMATIO

N:

Pharmacy NCPDP Number:

Organizational (Phcy) NPI Number:

Pharmacy Legal Name:

Pharmacy DBA Name:

Physical Address:

City:

State:

Zip:

Pharmacy Phone:

Pharmacy Fax:

Phcy. E-Mail Address:

State Board License:

DEA Number:

Federal Tax ID:

Medicare ID:

Medicaid ID:

Primary Contact’s Name: Title

(PIC, Mgr, Owner):

Email

:

Phone:

SECTION 2 - ADDITION/ACTIVE RELATIONSHIP AFFILIATIONSPlease list all active chain, franchise or third party relationships in the following table. The addition of an

:

exclusive

Primary Relationship Name:

Type 5 – Third Party Contracting Relationship will automatically terminate any existing Type 5 Third Party Contracting Relationships as of the new start date.

LeaderNet Exclusive: x Yes □ No *Primary Relationship Code: 603 *Payment Center Code: 003592

*Reconciliation Code: Relationship Type: □ Chain □ Franchise □ Buying Group □ 3rd Party Reconciliation x 3rd Party Contracting

*Related Provider Type: 3336C0003X Effective Date of Affiliation:

Additional Relationship Name: Exclusive: □ Yes □ No *Additional Relationship Code: *Payment Center Code:

*Reconciliation Code: Relationship Type: □ Chain □ Franchise □ Buying Group □ 3rd Party Reconciliation □ 3rd Party Contracting

*Related Provider Type: Effective Date of Affiliation:

Cardinal Health 7000 Cardinal Place Dublin, Oh 43017 888-887-5323

Pharmacy Affiliation Relationship Affidavit NCPDP 03/2011 Page 3

Additional Relationship Name: *Additional Relationship Code:

Exclusive: □ Yes □ No *Payment Center Code: *Reconciliation Code:

Relationship Type: □ Chain □ Franchise □ Buying Group □ 3rd Party Reconciliation □ 3rd Party Contracting

*Related Provider Type: Effective Date of Affiliation:

SECTION 3 - TERMINATION (ENDING) RELATIONSHIP AFFILIATIONSPlease end any and all relationships that are no longer active or will be ending in the near future. If you are adding your pharmacy to an exclusive relationship, please use this section to end all other relationships.

:

Primary Relationship Name: Exclusive: □ Yes □ No *Primary Relationship Code: *Payment Center Code:

*Reconciliation Code: Relationship Type: □ Chain □ Franchise □ Buying Group □ 3rd Party Reconciliation □ 3rd Party Contracting

*Related Provider Type: End Date of Affiliation:

Additional Relationship Name: Exclusive: □ Yes □ No *Relationship Code: *Payment Center Code:

*Reconciliation Code: Relationship Type: □ Chain □ Franchise □ Buying Group □ 3rd Party Reconciliation □ 3rd Party Contracting

*Related Provider Type: End Date of Affiliation:

Additional Relationship Name: Exclusive: □ Yes □ No *Relationship Code: *Payment Center Code:

*Reconciliation Code: Relationship Type: □ Chain □ Franchise □ Buying Group □ 3rd Party Reconciliation □ 3rd Party Contracting

*Related Provider Type: End Date of Affiliation:

*This form cannot be processed by NCPDP if the relationship and related Provider Types are not provided. Relationship Codes are 3-digits. Payment Center Codes and Remit and Reconciliation Codes are 6-digits. If you are uncertain of your Relationship Code, Payment Center Code or Remit and Reconciliation Code, please contact your relationship provider (PSAO). SECTION 4 – AUTHORIZATION TO PROCES

S:

Signature

: __________________________________________ Date

: ______________________

(Signature of contact from Page 1) Name __________________________________________

Title

: ______________________

(Print or type Name and Title) Note: This affidavit must be received by NCPDP within 30 days of the date signed above in order to be processed.

Confidential and Proprietary Caremark Provider Agreement

9/15/2009 ____________ Initial 1

CaremarkPROVIDER AGREEMENT

This Provider Agreement (the “Provider Agreement” or “Agreement”) is entered into between Caremark, L.L.C., a California limitedliability company and CaremarkPCS, L.L.C., a Delaware limited liability company (collectively “Caremark”), and the undersigned provider (“Provider”). Caremark and Provider agree as follows:

1. Definitions. Unless otherwise defined herein, capitalized terms used in the Agreement shall have the meanings set forth in the Glossary of Terms contained in the Provider Manual.

2. Credentialing. Provider represents, warrants, and agrees that as of the date of execution of the Agreement, Provider is and shall maintain in good standing, all federal, state and local licenses and certifications as required by Law. Provider will provide Caremark with the information required from time to time regarding Provider’s credentials, including, but not limited to Provider’s licensure, accreditation, certification, and insurance, and will comply with and maintain Caremark credentialing standards and requirements.

3. Provider Services and Standards. Unless Provider’s professional judgment dictates otherwise, Provider will render to all Eligible Persons the Pharmacy Services to which the Eligible Person is entitled in accordance with the Agreement, the prescriber’s directions, the applicable Plan, and applicable Law. Provider will submit all Claims for such Pharmacy Services electronically to Caremark in accordance with the Caremark Documents. Caremark may inspect all records of Provider relating to the Agreement.

4. Eligible Person Identification and Cost Share. Provider will require each person requesting Pharmacy Services to verify that he or she is an Eligible Person. With respect to each Covered Item dispensed to an Eligible Person, Provider will collect from the Eligible Person the applicable Patient Pay Amount communicated to Provider through the Caremark claims adjudication system or other method established by Caremark. Provider will not waive, discount, reduce, or increase the Patient Pay Amount indicated in the Caremark claims adjudication system unless otherwise authorized in writing by Caremark. Except for the collection of the applicable Patient Pay Amount, in no event will Provider seek compensation in any manner from an Eligible Person for Pharmacy Services with respect to a Covered Item.

5. Network Participation and Payment. Provider agrees to participate in the networks identified on the attached Schedule A according to the terms set forth therein. Caremark will pay Provider for Covered Items dispensed to Eligible Persons pursuant to the Agreement in accordance with Schedule A. Any overpayments made to Provider by Caremark may be deducted from amounts otherwise payable to Provider.

6. Compliance with Law. Provider will comply with all applicable Laws, including but not limited to those Laws referenced in the Federal and State Laws and Regulations section (and attached Addendums thereto) set forth in the Provider Manual.

7. Indemnification. All liability arising from the provision of prescription drugs and services rendered by Provider will be the sole responsibility of Provider. Provider will indemnify and hold harmless Caremark and Plan Sponsors and their respective shareholders, directors, employees, agents, and representatives from and against any and all liabilities, losses, settlements, claims, injuries, damages, expenses, demands, or judgments of any kind (including reasonable expenses and attorneys’ fees) that may result or arise out of (i) any actual or alleged malpractice, negligence, misconduct, or breach by Provider in the performance or omission of any act or responsibility assumed by Provider or (ii) in the provision of Pharmacy Services or the sale, compounding, dispensing, manufacturing, or use of a drug or device dispensed by Provider.

8. Limitation on Liability. In no event will Caremark be liable to Provider for indirect, consequential, or special damages of any nature (even if informed of their possibility), lost profits or savings, punitive damages, injury to reputation, or lossof customers or business.

Confidential and Proprietary Caremark Provider Agreement

9/15/2009 ____________ Initial 2

9. Term. The Agreement will begin on the date of acceptance by Caremark and will remain in effect until terminated in accordance with the Provider Manual.

10. Assignment. Neither party may assign this Agreement without the prior written consent of the other party; provided, however, that Caremark may, without consent, assign this Agreement to any direct or indirect parent, subsidiary, or affiliated company or to a successor company. Any permitted assignee shall assume all obligations of its assignor under this Agreement. This Agreement shall inure to the benefit of and be binding upon each party, its respective successors and permitted assignees.

11. Entire Agreement. This Agreement, the Provider Manual, and all other Caremark Documents constitute the entire agreement between Provider and Caremark, all of which are incorporated by this reference as if fully set forth herein and referred to collectively as the “Provider Agreement” or “Agreement”. Any prior agreements, promises, negotiations, or representations concerning the subject matter covered by the Agreement are terminated and of no force and effect. Provider’s non-compliance with any of the provisions of this Agreement, including the Provider Manual and other Caremark Documents will be a breach of the Provider Agreement. In the event there is a conflict between any of the provisions in this Provider Agreement, the Provider Manual, other Caremark Documents and a provision in an applicable State specific addendum attached to the Federal and State Laws and Regulations section of the Provider Manual, the terms of the applicable State specific addendum shall govern.

12. Waiver. Failure to exercise any of the rights granted under the Agreement for any one default will not be a waiver of any other or subsequent default. No act or delay shall be deemed to impair any of the rights, remedies, or powers granted in the Agreement.

13. Lawful Interpretation and Jurisdiction. Whenever possible, each provision of the Agreement shall be interpreted so as to be effective and valid under applicable Law. Should any provision of this Agreement be held unenforceable or invalid under applicable Law, the remaining provisions shall remain in full force and effect. Unless otherwise mandated by applicable Law, the Agreement will be construed, governed, and enforced in accordance with the laws of the State of Arizona without regard to choice of law provisions.

14. Headings. The headings of Sections contained in the Agreement are for convenience only and do not affect in any way the meaning or interpretations of the Agreement.

Confidential and Proprietary Caremark Provider Agreement

9/15/2009 ____________ Initial 3

Any changes to this agreement must be initialed. By signing below, Provider agrees to the terms set forth above and acknowledges receipt of the Provider Manual.

Pharmacy Name: _________________________________ Caremark, L.L.C.

NCPDP#: ______________________________________ ______________________________________ (Signature of Officer)

NPI#:__________________________________________

By: ____________________________________________ By:___________________________________ (Signature of authorized agent) (Print name of Officer)

_______________________________________________ Date___________________________ (Print name of authorized agent)

Date: __________________________________________ CaremarkPCS, L.L.C.

______________________________________ (Signature of Officer)

______________________________________ (Print name of Officer)

******ATTENTION********

PAGES 1, 2, AND 4 MUST BE INITIALED BY AUTHORIZED AGENT BEFORE CONTRACT WILL BE ACCEPTED

Confidential and Proprietary Caremark Provider Agreement

9/15/2009 ____________ Initial 4

SCHEDULE A NETWORK PARTICIPATION AND PAYMENT

This Schedule A is comprised of this Schedule A and all prior and subsequent network addendums and network enrollment forms, allof which are incorporated herein by this reference and referred to collectively as “Schedule A”. Provider agrees that it will participate in all Caremark and Plan Sponsor pharmacy networks in which: (1) Provider participates in as of the date of this Agreement; (2) Provider and Caremark have executed a network addendum or network enrollment form as of the date of this Agreement; (3) Providerand Caremark subsequently execute a network addendum or network enrollment form; and (4) Provider agrees to participate as evidenced by its provision of Pharmacy Services to an Eligible Person of a Plan Sponsor utilizing such pharmacy network(s).

Unless otherwise set forth in a network addendum or network enrollment form signed by both parties, claims submitted for a PlanSponsor participating in an Caremark or Plan Sponsor network will be reimbursed at the lower of: (i) AWP less the applicable AWPDiscount and Dispensing Fee less the applicable Patient Pay Amount; (ii) MAC plus the applicable Dispensing Fee less the applicable Patient Pay Amount; (iii) ingredient cost submitted by Provider plus the applicable Dispensing Fee less the applicable Patient Pay Amount; or (iv) Provider’s U&C price less the applicable Patient Pay Amount. The applicable AWP Discount and Dispensing Fee will be set forth in the applicable network addendum or network enrollment form. If Provider has not executed and delivered toCaremark a network addendum or network enrollment form, the applicable AWP Discount and Dispensing Fee will be the reimbursement rate as indicated in the claims system as to such claim. AWP Discounts and Dispensing Fees may be amended in accordance with the terms of the Agreement.

Notwithstanding any other provision in the Provider Agreement, claims (excluding compounded medications) submitted for a Plan Sponsor participating in a Caremark or Plan Sponsor network may be reimbursed at the lower of: (i) Price Type plus an applicablepercentage of the Price Type, or minus the applicable percentage of the Price Type, plus the applicable Dispensing Fee less theapplicable Patient Pay Amount (or if applicable Price Type is unavailable for a given drug, Caremark will pay Provider based upon AWP minus the applicable AWP Discount plus the applicable Dispensing Fee minus the applicable Patient Pay Amount); (ii) MAC plus the applicable Dispensing Fee less the applicable Patient Pay Amount; (iii) ingredient cost submitted by Provider plus theapplicable Dispensing Fee less the applicable Patient Pay Amount; iv. Provider’s U&C price less the applicable Patient Pay Amount; or (v) gross amount due less the applicable Patient Pay Amount.

Confidential and Proprietary Caremark Provider Agreement

9/15/2009 ____________ Initial 5

ADDENDUM TO PROVIDER AGREEMENT

The Provider Agreement is hereby amended, and the parties agree to the following as an addendum to the Provider Agreement.

1. Under the section heading titled “Indemnification”, the word “manufacturing” is deleted.

The parties hereto have caused this Addendum to Provider Agreement to be executed by their respective officers or representatives

duly authorized so to do effective the same date as the effective date of the Provider Agreement. By signing below, the undersigned

Provider represents and warrants to Caremark that it has read the Addendum to the Provider Agreement, and agrees to be bound by the

terms of the Addendum.

Pharmacy Name: ___________________________

NPI#: __________________________________

NCPDP#: __________________________________

By: _______________________________________ (print name of authorized agent)

___________________________________________ (signature of authorized agent)

Date: ______________________________________

Caremark, L.L.C. CaremarkPCS, L.L.C.

By:_________________________________ By: _________________________________ (Print name of Officer) (Print name of Officer)

______________________________________ ______________________________________ (Signature of Officer) (Signature of Officer)

Date: _________________________________ Date: _________________________________

Provider Enrollment - (480) 391-4623 Fax: (480) 661-3054 Network Enrollment - (480) 314-8457 Fax: (480) 314-8205

Authorized signer enrollment process:

1.

What LeaderNet can do to verify authorized signer:

a. When sending the pharmacy the Provider Agreement and Agency Addendum, inform the pharmacy that both addendums must be signed by the same person who signs the Caremark Enrollment Contract.

b. Suggestion: Keep an internal tracking sheet of who signs the Pharmacy’s Enrollment contract by communicating with the pharmacy when they return the Provider Agreement & Agency Addendum to the affiliation.

2. What the pharmacy can do to verify authorized signer:

a. Don’t know who the signer is?: i. First communicate internally by asking the pharmacist in charge.

ii. Call Provider Enrollment at 480-391-4623 to verify authorized signer. Have pharmacy NCPDP number available. If they have to leave a voicemail, have them leave their NCPDP, person calling, and direct phone number.

b. Previous signer left pharmacy: i. Verify if there was a change of ownership:

ii.

If there was a change of ownership or corporate restructure, the pharmacy needs to call Provider Enrollment to make necessary updates. Same ownership but previous authorized signer left company:

iii.

Have the pharmacy’s owner write a letter on the pharmacy letter head stating who they want as the authorized signer. Add a signer:

The pharmacy’s authorized signer can send Caremark a request by writing a letter on the pharmacy’s letter head stating who they would like to add to their authorized signer list. This letter can be faxed to Provider Enrollment at 480-661-3054.

3.

What information can Network Enrollment give to their affiliation for authorized signer?

a. We’ll encourage the affiliation to contact the pharmacy directly or have the pharmacy call Provider Enrollment line to verify signer information.

b. The affiliation can give the pharmacy the information on “what the pharmacy can do to verify authorized signer”, listed in #2 bullet.

Copyright © 2007 Express Scripts, Inc. Confidential and Proprietary All rights reserved. PSAO Services Agreement (Recontract) Revised 03/08 141763~v8

Schedule 2-1

SCHEDULE-2 Provider Authorization

The undersigned pharmacy (“Provider”) acknowledges and agrees that it has provided to Leader Drugstores, Inc., dba LeaderNET, Chain Code #603 (“PSAO”) all right and authority to act on its behalf to negotiate terms and conditions, including, but not limited to, reimbursement rates, PSAO deems appropriate for Provider to participate as a pharmacy in the network of open-door retail pharmacies created by Express Scripts, Inc. (“ESI”). Provider agrees to abide by all terms and conditions set forth in the agreements presented to PSAO by ESI including, but not limited to, the Pharmacy Provider Agreement (the “Provider Agreement”).

Provider acknowledges that (i) PSAO and ESI have entered into that certain Pharmacy Services Agreement (the “Services Agreement”) pursuant to which PSAO has agreed to perform certain services for ESI and (ii) in the event the Services Agreement is terminated for any reason, ESI shall have the right, but not the obligation, to terminate the Provider Agreement upon written notice to Provider.

By executing this Provider Authorization, the undersigned: (i) understands and agrees that any existing provider agreement with ESI, as amended by all amendments and addenda thereto, shall be superseded and replaced in accordance with the terms and conditions of the Provider Agreement; (ii) represents that he/she has the authority to, and by signing below hereby does, bind Provider to the terms and conditions set forth in the Provider Agreement, including the Binding Arbitration obligation contained therein, (iii) agrees that the rates, terms and conditions included in the and Provider Agreement represent Confidential Information and must not be disclosed to entities which are not the Provider or PSAO and (iv) authorizes PSAO to negotiate amendments/addenda to the Provider Agreement and hereby agrees to comply with any such terms and conditions contained therein as if negotiated directly by Provider.

This section is to be completed by Provider

ACCEPTED by duly authorized representative:

��������(NCPDP Number)

_______________________________________(State License Number)

�����������(NPI Number)

_______________________________________(Federal Tax ID Number)

_______________________________________(Pharmacy Name)

_______________________________________(Medicaid ID Number)

_______________________________________(DBA Name)

_______________________________________Remittance address if different than Pharmacy’s physical address

_______________________________________(Address)

_______________________________________(City) ______________________________________________________________________________

(Signature)_______________________________________(State, Zip Code)

_______________________________________(Print Name)

_______________________________________(Phone Number)

_______________________________________(Title)

_______________________________________(Fax Number)

_______________________________________(Date)

Please sign, date and return completed Attestation, ASAP. Signature:___________________________________ Date:___________________________

Medicare Part D Long Term Care Combo Shop Provider Agreement

Does your pharmacy service long term care facilities? Yes or No � If yes, please read document and sign only if you can agree to the criteria to

participate as a long term care combo shop provider. This is not intended for closed door LTC pharmacies.

� If no, please disregard.

Performance and Service Criteria for Network LTC pharmacies (NLTCPs) 1. Comprehensive Inventory and Inventory Capacity -- NLTCPs must provide a comprehensive inventory of Plan formulary drugs commonly used in the long-term care setting. In addition, NLTCPs must provide a secured area for physical storage of drugs, with necessary added security as required by federal and state law for controlled substances. This is not to be interpreted that the pharmacy will have inventory or security measures outside of the normal business setting.

2. Pharmacy Operations and Prescription Orders -- NLTCPs must provide services of a dispensing pharmacist to meet the requirements of pharmacy practice for dispensing prescription drugs to LTC residents, including but not limited to the performance of drug utilization review (DUR). In addition, the NLTCP pharmacist must conduct DUR to routinely screen for allergies and drug interactions, to identify potential adverse drug reactions, to identify inappropriate drug usage in the LTC population, and to promote cost effective therapy in the LTC setting. The NLTCP must also be equipped with pharmacy software and systems sufficient to meet the needs of prescription drug ordering and distribution to an LTC facility. Further, the NLTCP must provide written copies of the NLTCP’s pharmacy procedures manual and said manual must be available at each LTC facility nurses’ unit. NLTCPs are also required to provide ongoing in-service training to assure that LTC facility staff are proficient in the NLTCP’s processes for ordering and receiving of medications. NLTCP must be responsible for return and/or disposal of unused medications following discontinuance, transfer, discharge, or death as permitted by State Boards of Pharmacy. Controlled substances and out of date substances must be disposed of within State and Federal guidelines.

3. Special Packaging -- NLTCPs must have the capacity to provide specific drugs in Unit of Use Packaging, Bingo Cards, Cassettes, Unit Dose or other special packaging commonly required by LTC facilities. NLTCPs must have access to, or arrangements with, a vendor to furnish supplies and equipment including but not limited to labels, auxiliary labels, and packing machines for furnishing drugs in such special packaging required by the LTC setting.

4. Compounding/Alternative Forms of Drug Composition -- NLTCPs must be capable of providing specialized drug delivery formulations as required for

some LTC residents. Specifically, residents unable to swallow or ingest medications through normal routes may require tablets split or crushed or provided in suspensions or gel forms, to facilitate effective drug delivery.

5. Pharmacist On-Call Service -- NLTCP must provide on-call, 24 hours a day, 7 days a week service with a qualified pharmacist available for handling calls after hours and to provide medication dispensing available for emergencies, holidays and after hours of normal operations.

6. Delivery Service -- NLTCP must provide for delivery of medications to the LTC facility up to seven days each week (up to three times per day) and in-between regularly scheduled visits. Emergency delivery service must be available 24 hours a day, 7 days a week. Specific delivery arrangements will be determined through an agreement between the NLTCP and the LTC facility. NLTCPs must provide safe and secure exchange systems for delivery of medication to the LTC facility. In addition, NLTCP must provide medication cassettes, or other standard delivery systems, that may be exchanged on a routine basis for automatic restocking. The NLTCP delivery of medication to carts is a part of routine “dispensing”.

7. Emergency Boxes -- NLTCPs must provide “emergency” supply of medications as required by the facility in compliance with State requirements.

8. Emergency Log Books -- NLTCP must provide a system for logging and charging medication used from emergency/first dose stock. Further, the pharmacy must maintain a comprehensive record of a resident’s medication order and drug administration.

9. Miscellaneous Reports, Forms and Prescription Ordering Supplies -- NLTCP must provide reports, forms and prescription ordering supplies necessary for the delivery of quality pharmacy care in the LTC setting. Such reports, forms and prescription ordering supplies may include, but will not necessarily be limited to, provider order forms, monthly management reports to assist the LTC facility in managing orders, medication administration records, treatment administration records, interim order forms for new prescription orders, and boxes/folders for order storage and reconciliation in the facility.

10. IV Medications -- NLTCPs must have the capacity to provide IV medications to the LTC resident as ordered by a qualified medical professional. NLTCPs must have access to specialized facilities for the preparation of IV prescriptions (clean room). Additionally, NLTCPs must have access to or arrangements with a vendor to furnish special equipment and supplies as well as IV trained pharmacists and technicians as required to safely providing IV medications.

Medicare Part D Long Term Care Combo Shop Provider Agreement

I have read the covenants of this agreement and warrant to the best of my ability that I am a long term care combo shop provider and comply with the above requirements referenced on pages 1 and 2.

_____________________ ________________ Cardinal Account # NCPDP #

_________________________ ________________ Signature Date

_________________________Print Name

The pharmacy’s services area is (select one):

Within 5 miles: _______________________

Within 10 miles: _______________________

Other: ________________________

If this document is not signed, your pharmacy will not be listed as a long term care combo shop provider. This in no way terminates a pharmacy from participation in any other network.

*** Please note that this is not intended for closed door LTC pharmacies.

08/31/2009 08/31/2010

3,000,000

1,000,0001,000,000

1,000,000

1,000,000

01/13/2009 01/13/2010 1,000,0003,000,000

Business Associate Agreement Leader Drugstores, Inc.

This Business Associate Agreement (“Agreement”) is made by and between Leader Drugstores, Inc., a subsidiary of Cardinal Health, Inc. (“Leader”) and the undersigned pharmacy (“Pharmacy”). This Agreement pertains solely to services and information directly related to the program(s) described in the attached Exhibit A (the “Program(s)”) in which Pharmacy is participating and has an agreement for such services (the “Program Agreement(s)”).

In the course of providing services related to the Program(s), it is possible that Leader may receive from time to time Protected Health Information (“PHI”) from Pharmacy as that term is defined by 45 C.F.R. § 164.501. Leader, therefore, might constitute a “business associate” of Pharmacy within the meaning of 45 C.F.R. § 160.103. The purpose of this Agreement is to satisfy the requirements concerning “business associates” imposed by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and 45 C.F.R. Parts 160 and 164 (“Privacy and Security Regulations”), as amended by the provisions of Division A, Title XIII of the American Recovery and Reinvestment Act of 2009 (The Health Information Technology for Economic and Clinical Health Act) (“HITECH Act”) and all implementing regulations and other official guidance. Accordingly, Leader and Pharmacy agree as follows:

1. Definitions

2.

. Terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms in 45 CFR Sections 160.103, 164.501, 164.304 and the HITECH Act. For purposes of this Agreement, the “HITECH Compliance Date” shall mean February 17, 2010 unless an amended general effective date is established by legislation, regulation or in official guidance, in which case the amended date will be the HITECH Compliance Date.

Protection of Health Information

3.

. Leader's permitted and required uses and disclosures of PHI received from or on behalf of Pharmacy shall be limited to the uses and disclosures relating to the activities described in the attached Exhibit A, the Program Agreement(s) or this Agreement.

Prohibition on Unauthorized Use or Disclosure of PHI

4.

. Leader will neither use nor disclose any PHI received from or on behalf of Pharmacy, except as permitted or required by the Program Agreement(s), this Agreement, or as required by law, or as otherwise authorized in writing by Pharmacy. Leader will use appropriate safeguards to prevent the prohibited use or disclosure of PHI received from or on behalf of Pharmacy. The provisions of this Section 3 shall survive the termination of this Agreement.

Permitted Uses and Disclosure. Leader may not use or disclose PHI it receives from Pharmacy in a manner that would violate 45 C.F.R. Part 164 Subpart E if done by Pharmacy, except that Leader may use PHI it receives from Pharmacy as necessary for the proper management and administration of Leader and to carry out Leader's legal and contractual responsibilities. Leader may de-identify PHI it receives from Pharmacy pursuant to 45 C.F.R. § 164.514. Such de-identified information may be used and disclosed by Leader for any purpose. Leader may create or use a limited data set as defined in 45 C.F.R. § 164.514(e) to the extent both Pharmacy and Leader agree to do so. Effective not later than the HITECH Compliance Date, Leader will limit its uses and disclosures of Pharmacy’s PHI to uses and disclosures that comply with the Privacy Rule set forth in 45 CFR 164.504(e), specifically including but not limited to, the requirements of 45 CFR 164.504(e)(2) of the Privacy Rule, which lists the Implementation Specifications for Business Associate Agreements.

Page 2 of 10

5. Use, Disclosure or Request of Minimum Necessary Protected Health Information

6.

. Effective as of the HITECH Compliance Date or such earlier date as is required by the HITECH Act, Leader will determine the minimum necessary PHI to be disclosed for uses, disclosures or requests of, or for, Pharmacy’s PHI, other than those that are exempt from the “minimum necessary” standard specified in 45 CFR 164.502(b)(2), to accomplish the intended purpose of the use, disclosure, or request, consistent with the terms of the Program Agreements and/or specific determinations of the Pharmacy that are communicated to Leader.

Subcontractors and Agents

7.

. Leader will require each of its subcontractors or agents to whom Leader provides PHI received from Pharmacy to agree to written contractual provisions that impose at least the same obligations to protect such PHI as are imposed on Leader by this Agreement.

Accounting of Disclosures

8.

. Within ten (10) business days of notice by Pharmacy to Leader that it has received a request for an accounting of disclosures of PHI, other than related to treatment, payment or health care operations and not relating to disclosures made earlier than six (6) years prior to the date on which the accounting was requested, Leader agrees to make available to Pharmacy such information as is in Leader's possession and is required for Pharmacy to make the accounting required by 45 C.F.R. § 164.528. In the event the request for accounting is delivered directly to Leader, Leader shall, within ten (10) business days, forward such request to Pharmacy.

Accounting to HHS

9.

. Leader will make its internal practices, books, and records relating to the use and disclosure of PHI received from or on behalf of Pharmacy available to Pharmacy and to the Secretary of the United States Department of Health and Human Services (the “Secretary”) for purposes of determining Pharmacy's compliance with the Privacy and Security Regulations.

Designated Record Set

10.

. Pharmacy acknowledges that Leader shall not, by virtue of Leader's performance of services on behalf of Pharmacy, maintain a “Designated Record Set,” as that term is defined by 45 C.F.R. § 164.501, for Pharmacy regarding any individual.

Mitigation and Reporting

11.

. If Leader becomes aware of a prohibited use or disclosure of PHI that Leader received from Pharmacy or any Security Incident, then Leader shall promptly (i) use commercially reasonable efforts to mitigate any potential adverse effect of the use or disclosure or Security Incident; and, (ii) report the use or disclosure or Security Incident to Pharmacy.

Right to Terminate for Breach. Pharmacy may terminate this Agreement upon thirty (30) days written notice to Leader in the event Leader breaches any provision of this Agreement and such breach is not cured within such thirty (30) day period; provided, however, that in the event that termination of this Agreement is not feasible, Leader hereby acknowledges that Pharmacy shall have the right to report the breach to the Secretary. The termination of this Agreement shall have no effect upon any right or obligation created by any other written agreement between Leader and Pharmacy.

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12. Return or Destruction of Health Information

13.

. At the termination or expiration of this Agreement, Leader, if feasible, shall return or destroy and maintain no copies of PHI received from Pharmacy. To the extent that it is not feasible to return or destroy such PHI, the terms and provisions of this Agreement shall survive termination of this Agreement and such PHI shall be used or disclosed solely for such purpose(s) that prevented the return or destruction of such PHI. The provisions of this Section 12 shall survive the termination of this Agreement.

Pharmacy Obligations

14.

. Pharmacy shall provide Leader with the notice of privacy practices that Pharmacy produces in accordance with 45 C.F.R. § 164.520, as well as any changes to such notice as soon as such notice and any changes thereto are available. Pharmacy will also provide Leader in a timely manner with any changes in, or revocation of, permission by an individual to use or disclose PHI, if such changes affect Leader's permitted or required uses and disclosures. Pharmacy shall notify Leader in a timely manner of any restriction to the use or disclosure of PHI that Pharmacy has agreed to under 45 C.F.R. § 164.522, to the extent such changes affect Leader's permitted or required uses and disclosures.

Conformance with Modification of HIPAA or Privacy and Security Regulations

15.

. If an amendment to or modification of HIPAA or its implementing regulations, including the Privacy and Security Regulations, regulations implementing the HITECH Act and other official guidance, requires modification of this Agreement to permit Pharmacy or Leader to remain in compliance with HIPAA and its implementing regulations during the term of this Agreement, then Leader and Pharmacy shall enter good faith negotiations to amend this Agreement to conform to any change required by such amendment or modification.

Security

16.

. Leader agrees to implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic PHI that Leader creates, receives, maintains or transmits on behalf of Pharmacy as required by the Privacy and Security Regulations. Effective not later than the HITECH Compliance Date, Leader will be in compliance with the provisions of the HIPAA Standards for Privacy of Individually Identifiable Health Information set forth at 45 CFR 164.308 (Administrative Safeguards); 45 CFR 164.310 (Physical Safeguards); 45 CFR 164.312 (Technical Safeguards) and 45 CFR 164.316 (Policies and Procedures and Documentation Requirements) (collectively, the “Security Requirements”) in the same manner as the Security Requirements apply to Pharmacy.

Notice of Privacy and Security Breach

. In accordance with the HITECH Act, Leader is required to monitor and detect a breach of unsecured PHI accessed, maintained, retained, modified, stored, destroyed or otherwise held or used by Leader, in paper or electronic form. If Leader detects a breach, Leader must provide Pharmacy with notice of the breach within five (5) business days of the first day the breach is known, or reasonably should have been known, to Leader, including for this purpose any employee, officer, or other agent of Leader (other than the individual committing the breach). The notice will include the identification of each individual whose unsecured PHI was, or is reasonably believed to have been, subject to the breach. Leader must cooperate with Pharmacy in investigating the circumstances of the breach, as necessary to comply with providing any required notification of the individuals.

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17. Prohibition of Sale of Electronic Health Records

18.

. Effective not later than six (6) months after the date on which the Secretary publishes applicable final regulations, Leader will not, directly or indirectly, receive remuneration in exchange for Pharmacy’s PHI unless Leader or Pharmacy has obtained an authorization from the subject individual(s) which complies with all applicable requirements or unless an exception specified in Section 13405(d)(2) of the HITECH Act, 42 U.S.C. 17935(d)(2) or regulations published by the Secretary applies.

Indemnification

19.

. Pharmacy and Leader agree to indemnify, defend and hold harmless the other party from any claim, suit, demand, action, liability, damage, loss, cost or expense, including reasonable attorney's fees, brought against, made upon, or incurred by the other party because of or arising out of, any act or omission, (including without limitation any breach hereof) of the indemnifying party or its officers, directors, employees or agents in connection with the obligations imposed by this Agreement.

Term

. This Agreement shall be effective as of the effective date of the Program Agreement or if there is no written Program Agreement, as of the first day that Pharmacy discloses PHI to Leader, and shall remain in effect until the expiration or termination of the Program Agreement.

Pharmacy Name: ______________________

Signature: ____________________________

Print Name: ___________________________

Title: _________________________________

Date: ________________________________

Leader Drugstores, Inc.

Signature: __________________________

Print Name: _________________________

Title: _______________________________

Date: ______________________________

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Exhibit A to the Business Associate Addendum

Leader Drugstores Inc. Description of uses and disclosures of PHI related to the Program(s) listed below: The Cardinal Health Managed Care Connection Participation Agreement and Terms and Conditions of Participation; and related services such as enrollment status research, member eligibility research, claims research, claims experience, claims history, pricing research; and any other support related to the Program(s): • LeaderNET®

• Leader® Prescription Club

• ProfitLeaderSM

• Reconciliation

• Audit Assistance

• Reimbursement Assistance

• Medication Therapy Management Services

CENTRAL PAYMENT ENROLLMENT FORM

ALL FIELDS ARE REQUIRED – INCOMPLETE OR ILLEGIBLE INFORMATION MAY DELAY UPDATES TO THE PRISM CENTRAL PAY SYSTEM

Participating Store Agreement Date:______________________ (Please print legibly) Pharmacy Information: Sequence Number: __________ (Internal Use Only) Pharmacy Name: _________________________________________________________________________________________________________________ NCPDP (NABP#)______________________________ NPI#: _____________________________________________________________________________ Cardinal Health Servicing Division #:_________________________ Cardinal Health Customer #:_________________________________________________ Contact Name: __________________________________________________________________________________________________________________ Pharmacy Address: _______________________________________________________________________________________________________________ City: ____________________________________________________________________________ State: _________________________________________ Zip: ______________________________ Phone: (________) _______________________________ Fax: (________)_______________________________ E-mail address(es): _______________________________________________________________________________________________________________ (Email/fax information will be used only for sending deposit reports and remittance to the above contact and will not be released to any third-party)

ATTACH A VOIDED CHECK OTHERWISE ACH PAYMENTS CANNOT BE INITIATED TO THE PHARMACY Voided check must have the pharmacy name and address pre-printed on it (no temporary checks). If provided on a separate page, include NCPDP and/or NPI number on the additional page. In lieu of a voided check, the pharmacy may attach a document on either pharmacy or bank letterhead with the appropriate bank routing number and checking account number. If the pharmacy is sold in a future transaction, or if the bank account changes, please provide information to Central Pay as soon as available to avoid misrouted funds. Funds will continue to be disbursed to the account identified on this form until new information is provided.

Deposit slips do NOT provide the necessary information and are not acceptable.

Pharmacy hereby authorizes participating payers (PBMs) to send payment to a bank account designated by Cardinal Health, Inc. (Cardinal Health) and Carolina Coupon Clearing, Inc. dba Carolina Services Company, Inc. (Inmar). Pharmacy also authorizes PBMs to send associated payment remittance detail directly to Inmar. Pharmacy hereby authorizes Inmar and its financial institution to initiate payments to Pharmacy’s bank account. Inmar has the right to adjust future payments if payments previously made are found to be duplicate, in excess of requirements, or in error. Pharmacy understands that Inmar has no control over when Pharmacy’s financial institution makes funds available for withdrawal. If Pharmacy should close or change its account in any way, Pharmacy will notify Inmar to make the appropriate changes. Pharmacy will hold Inmar and Cardinal Health harmless for any loss which may arise solely by reason of error, mistake or fraud regarding information provided by Pharmacy. This Authorization shall be governed by and construed in accordance with the laws of the State of North Carolina. The parties hereto submit to the exclusive jurisdiction of the courts located within the State of North Carolina. This Authorization can be terminated by either party upon written notice to the other party. I represent and warrant that the above information is correct to the best of my knowledge and that I am authorized to sign this Enrollment Form on behalf of the Pharmacy agreeing to the terms on this form. ______________________________________________________________ Legal Name of Pharmacy By ___________________________________________________________ __________________________________

Authorized Signature Date ______________________________________________________________ Printed Name

NEW ENROLLMENT UPDATED CONTACT / EMAIL INFORMATION UPDATED BANK ACCOUNT INFORMATION CHANGE OF OWNERSHIP EFFECTIVE ______________ (For Change of Ownership, Page 2 of this form is required)

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Setting Customer Expectations (to be completed and returned by PBC)

Please review the following Weekly Enrollment Process with your customer:

1. Enrollment paperwork must be completed and accurate by EOD on Thursday to be reported to payors the following week (including NCPDP Online access and paperwork). Please see myCardinalHealth for LeaderNET® Enrollment Instructions and paperwork. Failure to turn in complete paperwork / NCPDP Online access will result in delayed enrollment in conjunction with processing issues.

2. LeaderNET® Pharmacies will be setup with MOST payors within 7 days of reporting. For the payors that do not take weekly reporting, customers should be ready to process within 26 to 46 days as there is currently no industry standard governing affiliation processing (these varying timelines are determined individually by the payors and not LeaderNET®).

3. New stores that haven’t filled prescriptions with Caremark or Medco in the past should allow for 30 to 45 days for account set-up with Medco and Caremark. Please see myCardinalHealth - “Additional Paperwork” for process.

I attest that I have reviewed the above information with my customer and will set expectations accordingly. Consultant Signature: _________________________

Consultant Printed Name: ________________________

Date: _____________________________