2016...Round to the nearest full mile How many prescriptions during the reporting period were...

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Purpose of This SurveyThe Tennessee Department of Finance and Administration (TennCare) engaged Mercer Government Human Services Consulting (Mercer), part ofMercer Health & Benefits LLC, to conduct a survey of Medicaid-enrolled pharmacy providers to better understand and determine the approximatecost of dispensing prescription drugs to TennCare beneficiaries.

Provider participation and timely response are crucial, as the information collected from this survey will be critical data for TennCare to betterunderstand the current pharmacy cost of dispensing. Submit any questions about this survey via email to [email protected] or call thePharmacy Survey Hotline at 1 (877)854-6776.

Please complete this survey for each TennCare participating pharmacy location in your company. If you wouldprefer to complete the survey on an Excel template rather than using this online tool, the template can be foundat the survey website for this project here: https://ghscapps.mercer.com/tnpharmacy/ .

*Enter your pharmacy's National Provider Identifier (NPI).Enter the National Provider Identifier (NPI) of the TennCare Medicaid provider.The NPI should be 10 digits long.

Enter your NCPDP provider number (if known).Should be seven digits.

*Enter the name of your pharmacy.Enter the name of the Medicaid provider

*Enter the street address of the provider.

Enter the provider address suite or mail stop.

*Enter the city where the pharmacy is located.

*Enter your pharmacy's state code (ex: Tennessee = TN).

*Enter your pharmacy's zip code.Enter the five-digit ZIP code where the provider is located.

*Enter the county where the pharmacy is located.

Page 1 of 21Survey Preview - TennCare PDFS

12/15/2016https://survey.mercer.com/Forms/Surveys/Preview.aspx?print=default&s=3779&loc=en-...

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*Enter the name of your pharmacy's contact person for this survey.

*Enter an email address for the contact person at your pharmacy.

*Enter the telephone number, including area code, where the contact person may be reached.

Enter the fax number, including area code, for the contact person.

*Does your pharmacy dispense 340B drugs?Indicate whether or not the provider dispenses drugs under the 340B Drug Pricing Program. Drugs dispensed under this program arereduced price outpatient drugs provided by drug manufacturers to eligible health care organizations or covered entities withdisproportionately high Medicaid populations.

Yes

No

*Choose the ownership type of your pharmacy.Indicate the type of ownership (e.g., independent, franchise, chain, or other).

Select:

Was there a change in pharmacy ownership during the reporting period?Note: The reporting period is the period covered by your most recently completed fiscal year for which you have financial statements. If yourfiscal year is a calendar year, then the reporting period would be from 1/1/2016 to 12/31/2016.

Yes

No

*Was the pharmacy open the entire year?If the pharmacy was open all 12 months of the reporting year, click Yes. If not, click No.

Yes

No

*Please enter the number of months the pharmacy was open.

*Please select your pharmacy typeIf you qualify for more than one, please select the type with the highest percentage of sales. See instructions for pharmacy type definitions.

Select:

*Please select the location of this pharmacy.Select:

*How many years has this location been open as a pharmacy?Indicate the number of years a pharmacy has operated at this location. This information is used for demographic analysis of the data.

of 21Survey Preview - TennCare PDFS


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*Is one or more of the pharmacists who fill prescriptions at this location also an owner of thestore or chain?

Indicate whether or not one or more of the pharmacists who fill prescriptions has been an owner of the pharmacy at any time during thereporting period.

Yes

No

*Does this pharmacy provide 24-hour emergency service?Yes

No

*How many hours per week is the pharmacy department open?The maximum number of hours is 168 (24 hours times 7 days per week).

*Is the pharmacy open 24 hours a day?Yes

No

Important Information

The operation of this tool is governed by this website's Terms and Conditions and Privacy Statement and you cannot be personallyidentified from the answers submitted to the questions. Mercer and its related companies will not be liable to you if your relianceon information obtained as a result of using the tool causes loss, damage or injury to you or any other person or entity.



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*At the end of the reporting period, what was the square footage of the prescription area?The prescription area will be defined as the medication receiving, storage, preparation, packaging, sales, and professional service areas.

At the end of the reporting period, what was the square footage of the non-prescription area?

At the end of the reporting period, what was the total square footage (prescription area + non-prescription area)?





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New Refill Total

Medicaid Fee-for-Service

Medicare (All parts) if available

All other

Total Scripts

30.Total Scripts Medicaid Only (fee for service)

Level 1

Level 2

Level 3

Total

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Less than 28 day supply Greater than or equal to a 28-day Supply

Unit Dose

Modified Unit Dose (Bingo Card/Blister packs)

No Unit Dose

Traditional Packaging

Other Method (Describe in comments)

Total LTC Scripts

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*Enter the number of scripts filled during the reporting period.Note: The reporting period is the most recently completed fiscal year and should correspond to the same time frame as your financialstatements or tax returns.

Enter the number of prescriptions that were compounded during the reporting period

How many prescriptions were delivered to the recipient?

*How many Medicaid prescriptions were delivered to the recipient?

What is the radius of the delivery area expressed in miles?Round to the nearest full mile

How many prescriptions during the reporting period were dispensed for long-term care (LTC)facilities in the following categories?



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What type of 340B pharmacy are you?Select:

Do you use a 340B administrator?

Yes

No

List the total number of 340B prescriptions filled during the reporting period.

List the total number of 340B prescriptions billed to Medicaid.Enter the total number of 340B prescriptions billed to Medicaid.





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Prescription Counts Revenue

Blood Factor

All Other Specialty

Total Specialty

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Specialty Dispensing Information:Enter the script counts and revenue for drug classes listed below.





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*Please enter beginning date range of financial reports.This is the beginning date of the reporting period.

*Please enter the ending date range of financial reports.This is the ending date of the reporting period.

Sales:Enter the following sales information rounded to the nearest dollar.Note: Calculated percentages of sales in the categories below determine allocation rates for certain administrative costs to the pharmacydepartment as a cost of dispensing.

*What were your prescription sales?Do not include 340B sales or over-the-counter sales.Include sales for all prescriptions filled, including specialty revenue.

*What were the OTC sales (dispensed by pharmacy department)?

What were the OTC sales (not dispensed by the pharmacy department)?

*What were the sales of drugs purchased through the 340B program?

*What portion of federal grants, if any, are attributable to pharmacy?

Professional pharmacy services billed through medical claims

Revenue for special packaging, including blister packs.

Revenue for compounding from all payers.

Revenue for medication therapy management (MTM) from all payers.



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List the amount of other sales (e.g., services, candy, greeting cards).

Enter total sales for the reporting period.This amount should tie to the total sales on your financial statements or tax return.





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Enter cost of goods sold (COGS) for all pharmaceuticals. (Note - this will not be included in thedispensing fee calculation).

This amount will be used for validation purposes only.

Enter COGS for non-pharmaceutical sales.

Pharmacy Department ExpendituresDo not include ingredient costs in any of the questions in this section.

*List pharmacy department expenditures for prescription containers, labels, and other pharmacysupplies.

*List pharmacy department expenditures for professional liability insurance for licensedpersonnel.

*List pharmacy department expenditures for prescription department licenses, permits and fees.

*List pharmacy department expenditures for dues and subscriptions.

*List pharmacy department expenditures for prescription related delivery expenses.

List expenses for compounding, including depreciation for compounding equipment.

*List pharmacy department expenditures for bad debts for prescriptions (including uncollectedcopayments).

*List pharmacy department expenditures for computer systems costs related only to theprescription department.



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List expenses for claim transmission charges.

*List pharmacy department expenditures for depreciation - directly related to pharmacydepartment, including computers, software, and equipment.

*List pharmacy department expenditures for professional education and training.

*List pharmacy department expenditures for costs directly attributable to 340B programmanagement.

*List pharmacy department expenditures for other costs directly attributable to 340B (Please listin comments section).

*List pharmacy department expenditures for other prescription department-specific costs notidentified elsewhere (if greater than 5% of the total prescription department costs). Please explainin the comments section.





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71.Wages, bonuses, and guaranteed

paymentsPercentage of time spent in the pharmacy

department

Owner Pharmacist

Pharmacy Manager (non-owner)

Staff Pharmacists

Pharmacy Technicians

Delivery Personnel

Other Unlicensed Personnel in the PharmacyDepartment

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Number of Pharmacist full time equivalents (FTEs)An FTE works 2080 hours per year

Non pharmacist FTEs working in the pharmacy department

*Pharmacy Department Personnel and Labor Costs

Pharmacy department payroll taxes

Pharmacy Department benefits, including health insurance and pension / profit sharing /retirement programs.

Wages for Personnel Directly Attributed to Non-pharmacy Sales & Services

Wages for Personnel Directly Attributed to Administrative or Shared Services

Payroll Taxes, and Benefits not reported elsewhere

General Employee Expenses Attributable to All Employee Types not reported elsewhere.



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Facility CostsBackground information is needed to ensure appropriate expenses are captured and to identify potential outliers that require adjustment orexclusion. Most facility costs are allocated to the costs of dispensing by percentage of square footage.

*Do you or does a related party own the building?

Yes

No

*Is the building fully depreciated?

Yes

No

*If owned by you or a related party, what is the amount of the building depreciation expense inthe reporting period?

*What are your rent expenses?If you own the building, please explain any rent expenses in the comments section.

*What are your utilities expenses (gas, electric, water and sewer)?

List the amount of your real estate taxes.

List the amount of facility insurance expenses.

List the amount of the maintenance and cleaning expenses.

List the amount of the depreciation expenses for leasehold improvements, furniture and fixtures.

List the amount of the mortgage interest expenses.



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List the amount of the other facility specific costs not identified elsewhere (if greater than 5% ofyour total facility costs, please attach supporting details in the comments section).

Other Store/Location Expenses

Allowable other store/location expenses are allocated to the pharmacy dispensing fee calculation as a percentage of sales. Do not include payrollexpenses previously reported.

List the amount of the marketing and advertising expenses.

List the amount of professional expenses (e.g., accounting, legal, consulting).

List the amount of security expensesEnter the costs for security systems and monitoring.

List the amount of telephone and data communication expenses.

List the amount of transaction, merchant and credit card fee expenses.

List the amount of computer systems and support expenses.Do not include costs reported previously as pharmacy department computer system costs.

List the amount of depreciation expenses (all other - including, equipment, furniture andcomputers).

Do not include depreciation previously reported.

List the amount of amortization expenses.

List the amount of office supply expenses.

List the amount of office expense.

List the amount of other insurance expenses.

List the amount of tax expenses (other than real estate, payroll and sales).



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List the amount of franchise fees (if applicable).

List the amount of other interest expenses.Do not include mortgage interest previously reported.

List the amount of charitable contributions.

List corporate overhead.

List the amount of other costs not included elsewhere (if greater than 5% of the total otherstore/location costs, please attach supporting documents in the comments section).





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*Enter the total net sales from your financial statements or tax return.

*Enter the total payroll expense from your financial statement or tax return.Include owner and employee wages, bonuses, and guaranteed payments.

*Enter the total expenses from your financial statements or tax return.





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Enter any comments or clarification to any previous questions here. Please clearly identify thetopic for which you are entering comments or clarification.





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*Survey Certification: I declare that I have examined this cost report including accompanyingschedules and to the best of my knowledge and belief, it is true, correct and complete.

For your electronic signature please enter your name.

Please enter your position/title.

You have answered all of the questions. Please click Finish below to complete the survey.





Thank you for taking the survey.

(User Survey Response)

If you have any questions about the survey process, please email us at [email protected].

Thank you for completing the survey!





2016...Round to the nearest full mile How many prescriptions during the reporting period were...

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