Physician Dispensing Services | Doctor Dispensing - BRP Pharmaceuticals

1. PHARMACEUTICALS BRP Physician Dispensing at point-of-care What is Physician Dispensing & Point of Care Dispensing? Physician dispensing enables doctors and clinics to offer their patients timely, convenient, and hassle-free alternatives for receiving their medication. ! Regulatory Compliance Under current medical licenses, physicians are permitted to dispense medications at the office directly to patients with no restrictions in 44 states. BRP is licensed by the FDA and DEA. Physician dispensing is supported by the American Medical Association. Physician dispensing is regulated at the state level by the state board of pharmacy. ! Medication Adherence & Procedure Concerns in the US !! of patients do not adhere to prescription medication regimen 50% 30% of prescriptions are never filled at all $100 billion spent each year in avoidable hospitalizations as a result [ New England Journal of Medicine, April 29, 2010, Volume 362, Number 17 ] ! Point-of-Care Dispensing Offers Multiple Benefits to your Patient !!!!!!!!!!!! Point-of-Care Dispensing Offers Multiple Benefits to your Practice Adherence & Compliance Convenience Cost Savings Providing the medication to the patient in the office improves patient compliance to doctors’ prescribed orders. Point-of-Care eliminates the extra trip and inevitable wait at the pharmacy for elderly and those with acute symptoms or transportation issues. Most medications dispensed by physicians are generic and can be sold at or below a patient’s standard co-pay. $ $ $ $ Expand Offered Ancillary Services Additional Revenue Stream Better Manage Patients’ Health Less Hassle Frees up Staff Time

2. PHARMACEUTICALS BRP ???????????? What we do ? BRP has been in the pharmacy business for over 100 years and repackaging medications since 1980. Today, BRP is a trusted provider to over 2000 physicians, clinics, and pharmacies across the United States, servicing clinics across 32 specialties ? BRP has access to the broadest range of quality pharmaceuticals, building strong relationships with various manufacturers and distributors to gain access to all generic and branded products. If a clinic needs a product we either have it or will find it for them. ? ? ? 25 ??? 13 3 1 12 2 13 23 49 2 ????? 69 5 83 29 13 5 40 144 13 3 1-24 2 25 59 612 11 18 14 25-49 36 100 61 60 50-99 2 69 ? ??????????? ?????????????? 4 154 60 24 100-612 34 364 How we do it We repackage bulk medications into smaller bottles, label, and ship the final product to the office, allowing physicians to dispense medication directly to the patients at the time of the visit. ? BRP follows rigorous safety and quality standards. We are licensed with the FDA and DEA, and hold a pharmacy license in all 45 states that support physician dispensing. How we started Founded in 2004 and headquartered in Burbank, CA, Bryant Ranch Prepack, Inc. is a leader in the re-packaged pharmaceuticals industry. In 1980, a doctor requested that one of our stores in La Mirada, California prepackage a few medications so that sick patients would not have to wait for their prescriptions to be counted out. Within a few months, the doctor asked us to provide pharmaceuticals to his clinic on a regular basis, and Bryant Ranch Prepack was born. ? Though BRP has continued to grow into the industry leader that it is today, the company aims to maintain the same “family run business” principles established so long ago. This family mentality is reflected in our dedication to patient care and clinical excellence.

3. PHARMACEUTICALS BRP ????????????????????????????????????????????????? Regulatory Compliance: American Medical AssociaTIon AMA’s Code of Ethics Opinion 8.06 - Prescribing and Dispensing Drugs and Devices ?????????? Source: American Medical Association, Issued June 2002. This opinion is a consolidation of previous Opinions 6.04, "Fee Splitting: Drug or Device Prescription Rebates;" 8.06, "Drugs and Devices: Prescribing;" and 8.07, "Gifts to Physicians: Offers of Indemnity.” ??What This Means for You and Your Practice ? Point-of-care dispensing places a premium on issues such as patient convenience and compliance with medication while providing a benefit to the physician over practice revenue. “ Physicians may dispense drugs within their office practices provided such dispensing primarily benefits the patient…In all instances, physicians should respect the patient’s freedom of choice in selecting who will fill their prescriptions as they are in the choice of a physician and, therefore, have the right to have a prescription filled wherever they wish.” Regulatory Compliance: Who can dispense Under their current license, physicians are allowed to dispense medications, directly to their patients at the point-of-care, from their office, with no restrictions, in 44 states. Allowed Restricted Munger et al., Pharmacotherapy, Oct 2014, Volume 34, Number 10: 1017

4. PHARMACEUTICALS BRP !!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!! Benefits for your patient Convenience Receiving medications at the time of the office visit eliminates the extra trip to the pharmacy & waiting 30-60 minutes for the prescription to be filled. This is especially meaningful for elderly patients, patients with acute symptoms and patients with transportation issues. ! Cost Savings Most medications dispensed by physicians are generic and can be sold at or below a patients’ standard co-pay. ! Confidentiality Patients can be sensitive about privacy of their illnesses and medications, the confidentiality of receiving their medication at the medical office is a major plus. ! Adherence & Compliance Providing the medication to the patient in the office improves the odds of patient compliance to doctors’ prescribed orders. Benefits for your Practice Patient Health Management Increasing patient adherence allows providers to better manage patients’ health !!!!!!! Increased Offered Services Medication dispensing is a primary ancillary service received by patients from their primary care physician: !!!! Increased Revenue Stream Dispensing medications directly from the office allows a practice to expand offered ancillary services, thereby increasing revenue “ As many as 50% of patients do not adhere faithfully to their prescription medication regimen, while 30% of prescriptions are never filled at all. The result is more than $100 billion spent each year in avoidable hospitalizations. New England Journal of Medicine, April 29, 2010, Volume 362, Number 17 ” 38% 36% 34% Lab Services Drug Dispensing Radiology

5. PHARMACEUTICALS BRP !!!!!!!!!!!! !!!!!!!!!!!!!!!!! Benefits for your Staff Staff Convenience Less staff time spent on the phone with pharmacies. ! 5 Steps, 2 Minutes After brief and simple training, properly dispensing a prescribed medication takes generally 2 minutes. Physician Dispensing Process: 5 steps, 2 minutes 1 2 3 4 5 Enter the patient's details into the software !! Select the medications to be dispensed and add them to the patient’s record !! Patient pays for medication !!Print medication label and patient education sheet, available in English or Spanish !!Apply patient-specific label to the bottle and dispense to patient. The patient leaves the office with everything they need to begin recovery/treatment. Physician testimonials “BRP’s dispensing program is easy for our patients and they really like the service. The labels are correct so there are no errors and the cost is usually lower than co-pays.” Mahfouz Michael, M.D. President, Clinica Medica San Miguel “In urgent care it is important to treat the patient quickly and comprehensively. BRP’s program helps us give complete care in one visit.” Konstantinos Melahouras, M.D. President, Southland Family, Urgent Care

6. PHARMACEUTICALS BRP startup costs and equipment Cost to get Started: - Just the cost of the initial med order. •Use of the MDscripts Dispensing Software FREE(Comes complete with 24/7 IT support) •Personalized account management by BRP’s Customer Service center and 
 initial webinar training program with you and your staff. FREE •Labels are FREE •Paper Dispensing Bags are FREE(Comes in Packs of 100 Bags) •Shipping and handling fees only apply if your order is under $150.00, otherwise you 
 receive FedEx Shipping FREE. (*Expedited shipping is available but it is at your expense.) ! Equipment Needed: •The beauty of our program is that if you have a Computer, you already have 
 everything you need to get started. •2D Barcode Scanner (Optional): The dispensing software supports a 2-Click dispensing system as well as use with a scanner. •Label Printer (Optional): The printer will print out a personalized label with pertinent patient/ office info Setting up an account with BRP pharmaceuticals Develop the Formulary Obtain physician’s formulary with size and strength of most commonly prescribed meds BRP will provide a detailed price analysis based on the formulary Physicians will review the formulary analysis and select medications they would like to carry ! Staff Participation A staff member will be assigned to oversee the dispensing system. ! Documentation Photocopy of prescribing physician’s State License If dispensing controlled substances, a photocopy of the physician’s DEA License If required by the State, a photocopy of physician’s State Dispensing License Completed BRP Application ! Medication Order Provide an opening order. We suggest a 2-3 week supply to start

7. PHARMACEUTICALS BRP Legality and risk How is this regulated? 44 out of 50 states in the United States, it is absolutely legal for physicians to do point-of-care dispensing without restriction. Physicians have the legal right to dispense medicine to their patients under their current license. Malpractice Risk? In general, the insurance industry does not view medication dispensing as an increased risk of practicing medicine. The actual risk is in the decision regarding which medications, and combinations of medications that are prescribed, not necessarily where medications are filled !! Are other physicians and prescribers doing this? Ancillary services offered in physician offices are increasing, as physician reimbursement decreases and patient satisfaction becomes more important Lab Services, Drug Dispensing, and Radiology are three ancillary services most commonly offered by primary care physicians In 2010, roughly 10% of practicing physicians offered in-office dispensing, and trends indicate that physician dispensing with grow by approximately 25% in the coming years As an industry leader, BRP Pharmaceuticals currently serves over 2000 physicians across 44 states !! Convenience Patients appreciate receiving medications in the physician’s office to avoid an additional trip to the pharmacy and waiting 30-60 minutes for their prescription to be filled This is especially meaningful to patients with acute symptoms and patients who have transportation issues Adoption trends impact on patients Compliance & Adherence According to the New England Journal of Medicine, as many as half of all patients do not adhere faithfully to their prescription-medication regimens. Furthermore, approximately 20%-30% of medication prescriptions are never filled at all. Data estimates that more than $100 billion spent each year on avoidable hospitalizations due to prescription non-adherence. Providing the medication to the patient in the office improves the odds of patient compliance with doctors’ prescribed orders. !! Impact on office staff training is minimal Current technology and software platforms have created a turnkey process, automating the dispensing process through a user-friendly, personalized software, or an internet based system. impact on staff Impact on office staff capacity is time-neutral Many practices currently dispensing in office report that dispensing in office has reduced the number of calls, back-and-forth, between the office staff and pharmacies It is estimated that each call to/from a pharmacy costs $7. Reducing this traffic, and replacing it with revenue-generating activity, practices are able to collect revenue for the prescription work that they do, rather than waste employee capacity.

8. PHARMACEUTICALS BRP ????????? Regulatory Compliance: who can dispense MD, DO, DDS, DPM, DVM, PA, NP can dispense Limited to MD, DO, DDS, DPM, DVM how is in-office dispensing regulated? No registration required Registration required No specific requirements Some requirements Must follow all requirements Munger et al., Pharmacotherapy, Oct 2014, Volume 34, Number 10: 1017

9. PHARMACEUTICALS BRP ????????????????????????????????????????????????? ! Legislative Counsel State of California Article 12. Prescriber Dispensing !4170. Dispensing by Prescriber: Requirements and Restrictions; Enforcement a) No prescriber shall dispense drugs or dangerous devices to patients in his or her office or place of practice UNLESS ALL OF THE FOLLOWING CONDITIONS ARE MET: 1) The dangerous drugs or dangerous devices are dispensed to the prescriber's own patient, and the drugs or dangerous devices are not furnished by a nurse or physician attendant. 2) The dangerous drugs or dangerous devices are necessary in the treatment of the condition for which the prescriber is attending the patient. 3) The prescriber does not keep a pharmacy, open shop, or drugstore, advertised or otherwise, for the retailing of dangerous drugs, dangerous devices, or poisons. 4) The prescriber fulfills all of the labeling requirements imposed upon pharmacists by Section 4076, all of the recordkeeping requirements of this chapter, and all of the packaging requirements of good pharmaceutical practice, including the use of childproof containers. i. Name of the patient, Name of the prescriber, Date of issue, Name and address of the prescriber, and prescription number or prescription ID, Strength of the drug or drugs dispensed, Quantity of the drug or drugs dispensed, Directions for the use of the drug, Expiration date of the drug or drugs dispensed 5) The prescriber does not use a dispensing device unless he or she personally owns the device and the contents of the device, and personally dispenses the dangerous drugs or dangerous devices to the patient packaged, labeled, and recorded in accordance with paragraph(4). 6) The prescriber, prior to dispensing, offers to give a written prescription to the patient that the patient may elect to have filled by the prescriber or by any pharmacy. 7) The prescriber provides the patient with written disclosure that the patient has a choice between obtaining the prescription from the dispensing prescriber or obtaining the prescription at a pharmacy of the patient's choice. b) The Medical Board of California, the Osteopathic Medical Board of California, the Board of Registered Nursing, the Veterinary Medical Board, and the Physician Assistant Committee shall have authority with the California State Board of Pharmacy to ensure compliance with this section, and those boards are specifically charged with the enforcement of this chapter with respect to their respective licensees. !4171. Exceptions to Section 4170: Samples; Clinics; Veterinarians; Narcotic Treatment Programs; Certain Cancer Medications a) Section 4170 shall not prohibit the furnishing of a limited quantity of samples by a prescriber, if the prescriber dispenses the samples to the patient in the package provided by the manufacturer, no charge is made to the patient therefore, and an appropriate record is entered in the patient's chart. !4172. Storage Requirements A prescriber who dispenses drugs pursuant to Section 4170 shall store all drugs to be dispensed in an area that is secure. The Medical Board of California shall, by regulation, define the term "secure" for purposes of this section. !4173. Dispensing by Registered Nurses This chapter does not prevent the dispensing of drugs or devices by registered nurses functioning pursuant to Section 2725.1. !! Medications Stocking Reports, CURES reporting, invoices, and other inventory management actions are required to legally dispense medications out of your office – software has been developed to automatically manage and send these reports to the proper regulating entities.