Form 3

Let's Work Together!

Thank you for your interest in our new Team Cuban Benefits Card!

1.The pharmacy I'm completing this form for is an open-door, walk-in retail pharmacy open to the public.

(If not, please do not complete this form. At this time, we seek only open retail, open-door, walk-in community practice pharmacies open to the public.)

2. First & Last Name

3. Your Title at the Pharmacy (PIC, staff pharmacist, owner, pharmacy technician, etc.)4. Your Phone Number (999-999-9999)5. Please list your email address and any other email addresses that serve as the primary contact for the pharmacy:6. Your Pharmacy's LEGAL ENTITY NAME (Please only one pharmacy per form):7. Your Pharmacy's DBA Name (if relevant):8. Your Pharmacy's NPI #:9. Your Pharmacy's NCPDP #:10. Your Pharmacy's street address only (Ex: 1234 Anywhere Lane)11. Your Pharmacy's city12. Your Pharmacy's home state:13. Your Pharmacy's zip code:14. If located in Louisiana, which county or parish does your pharmacy reside in?15. Your Pharmacy's PHONE NUMBER (for the public): 16. Your Pharmacy's FAX number:17. General Email address for the Pharmacy:18. Your Pharmacy's billing street address if different from street address only (Ex: 1234 Anywhere Lane)19. Your Pharmacy's Billing City20. Your Pharmacy's Billing State21. Your Pharmacy's Billing Zip Code22. Your Pharmacy's BILLING EMAIL ADDRESS:23. Website URL of your Pharmacy (if you have a website):24. Link of your pharmacy on Google Maps: (Please provide the actual URL on Google maps to your pharmacy - do not respond "Yes".)25. State Tax ID # of your Pharmacy:26. Federal Tax ID # of your Pharmacy:27. Medicaid #28. Medicare #29. DEA Number of your Pharmacy:30. DEA Registration Expiration Date: (Please format as MM/DD/YYYY)31. Home State Pharmacy License #:32. Home State Pharmacy License Expiration Date: (Please format as MM/DD/YYYY)33. Mailing address (if different from pharmacy address):34. Wholesaler Information35. Pharmacy Hours - please start with SUNDAY and provide through SATURDAY:36. Software vendor(s) - for pharmacy fulfillment:37. Contact name and information for Software Vendor:38. Pharmacy Switch Name through Software vendor:39. Is your pharmacy in contract with your Software Vendor or Switch to transmit or collect data other than to process claims? Y/N:40. Pharmacy Liability Insurance Carrier Name:41. Pharmacy Liability Insurance Policy #42. Amount per OCCURRENCE of insurance and / Amount IN AGGREGATE? (example: $1 million / $3 million)43. Pharmacy Liability Insurance Expiration date: MM/DD/YYYY44. Owner(s) name(s) of Pharmacy45. Pharmacist In Charge's (PIC's) name:46. PIC's license number AND STATE of license:47. Who will be the signatory of your contract for this pharmacy?48. What is your signatory's title?49. What is your signatory's email address?50. Other than the current name above, has the pharmacy operated under any other trade or business name(s)? If yes, please provide details and name(s).51. List all states where your Pharmacy maintains active license(s).52. Is your pharmacy URAC accredited? Y/N. If YES - is it accredited for: mail order, specialty or both? If yes, what is the expiration date(s) on the URAC accreditation(s)?53. Are you a provider for and is your pharmacy eligible to distribute Drug Products under the Public Health Service Act, Section 340(B)?54. Under current ownership, has this pharmacy, or any of its principals, ever filed for bankruptcy or reorganization?55. Will the pharmacy maintain patient profiles, prescription, and signature logs as required by applicable State, Federal and U.S. territorial laws, and advise members that their signature acknowledges their receipt of prescriptions and allow release of any and all claim information?56. Has the pharmacy or any of its present owners, officers, or employees ever been convicted of any state or federal law convictions? If yes, please provide a detailed explanation.57. Does the pharmacy comply with all State/Federal/U.S. territorial regulations, including CMS rules and regulations?58. Do you have a written policy to actively review business operations and finance to minimize potential fraud waste and abuse? If no, please provide a detailed explanation.59. Does your pharmacy have any offshore activity that involves the use of PHI? (i.e. Call Center, claims reconciliation, etc.) If yes, please provide a detailed explanation.60. Does your pharmacy comply with the regulations to protect PHI?61. Has pharmacy previously been suspended, terminated or excluded from any Pharmacy Benefit Management (PBM) network in the past five (5) years for cause? If yes, please provide a detailed explanation.62. To the best of your knowledge, has or will Pharmacy or any of its locations, pharmacists, subcontractors, or other personnel furnishing (or which will furnish) prescription services been or be (i) listed as debarred, excluded, or otherwise ineligible for participation in federal health care programs or (ii) convicted of a criminal felony (for North Carolina, Tennessee and Vermont pharmacies, please include misdemeanor convictions)? If yes, please provide a detailed explanation.63. What is the most recent date your pharmacy was inspected by any State Board of Pharmacy?64. Do you have or offer a home infusion for medical drugs as part of your pharmacy?65. By signing below, I hereby confirm that, in the event the answers to the foregoing questions change, l will provide updated answers to these questions in writing no less than 10 days from the date of such changed circumstances.

Certification of Authorized Pharmacy Representative

I certify, represent and warrant that any and all information provided to each of the items related to this Enrollment Form and in connection with the enrollment and credentialing process, is true, accurate and complete and it has not failed to state any facts or provide any documents that may be material to Mark Cuban Cost Plus Benefits, LLC in connection with its enrollment/credentialing process. Failure to provide true, accurate, and complete information in this credentialing application may result in sanctions, up to and including denial to participate and/or termination from the Mark Cuban Team Card Program.

PLEASE PROVIDE YOUR FULL NAME FOR SIGNATURE BELOW:66. Name of Authorized Pharmacy Representative:67. DATE

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3 - Indie Pharmacy Demographics & Due Diligence Form - Cuban Affiliate Pharmacy Network 01/08/2024

Let's Work Together!