Exhibit_A.pdf

Exhibit A to Section B: Contract Data Requirements List (CDRL) DD Form 1423 Summary List

HT9402-13-R-0001 – Amendment 0006 1

D010 MTF Reject Detail Reports D020 Retail Pharmacy Claims (RPC) Data Requirements D030 Contractor Payment – Check Issue Data W010 MTF Data Integrity Report W020 MTF High Cost Claim Report M010 Network Pharmacy Report M020 Network Access Report M030 Pharmacy Claims Processing System Availability Report M040 HIPAA Privacy Disclosure Report M050 Supervisory Review Report M060 Deployment Prescription Program Report M070 Educational Update Report M080 Priority Correspondence Report M090 Call Center Top Issues Report M100 TPharm Metric Summary Report M110 MTF to TMOP Transfer Report M120 Pharmacy Claims Audit Report M130 Bank Account Reconciliation Report M140 Accounts Receivable Reports M150 Bank Cleared Payment Reports M160 Bank Account Statement M170 MTF Data Integrity Summary Report M180 MTF Reject Summary Report M190 Mail Order Reconciliation Report M200 Mail Order Replenishment Reconciliation Report – Claims Level Data File M210 Mail Order Replenishment Reconciliation Report – NDC Level Data File M220 MTF High Cost Claim Summary M230 Plan Cost Report M240 TMDS Claims Volume M250 TFL Pharmacy Pilot Summary and Savings Report M260 TFL Pharmacy Pilot Override Report M270 TFL Pharmacy Pilot Opt-Out Report Q010 Paper Claims Aging Report Q020 Denied/Appealed Paper Claims Report Q030 Mail Order Pharmacy Prescription Report Q040 Mail Order Pharmacy Reship Report Q050 Quality Control Report Q060 Specialty Pharmacy Services Report Q070 Call Center Utilizers Data File Q080 Mail Order Pharmacy Utilizers File Q090 Clinical and Admin Review Report Q100 Prescription Restriction Program Report Q110 Beneficiary Services Report Q120 Pharmacy Help Desk Report Q130 EOB Report Q140 Retail Prescription Transfer Report Q150 Mail Order Pharmacy Partial Fill Report Q160 TED Summary Report Q170 CHCBP Monitoring Report Q180 Quality of Adjudication Audit Report

Exhibit A to Section B: Contract Data Requirements List (CDRL) DD Form 1423 Summary List

HT9402-13-R-0001 – Amendment 0006 2

Q190 OHI Development Report Q200 Plan Costs vs Commercial Plans Q210 Fraud and Abuse Summary Report Q220 Step Therapy Enhancements A010 MOU with PDTS A020 MOU with MCSC for North Region A021 MOU with MCSC for South Region A022 MOU with MCSC for West Region A030 MOU with TMA Beneficiary Education and Support Division (BE&S) A040 Statement on Standards for Attestation Engagements (SSAE No. 16) A050 Continuity of Operations Plan A060 Disaster Recovery Test Results A070 Enhanced Safeguarding Information Requirements A080 TPharm Payer Sheet A090 Interface Control Document A100 FOIA Releasable Contract R010 Pharmacy Change Monitoring Report R020 Operations Issue Log R030 Ad Hoc Management Reports T010 Phase-In Transition Plan T020 Phase-In Transition Status Report T030 Phase-Out Transition Plan T040 Phase-Out Transition Status Report