<p> Electronic Prescribing (eRx) Initiative Data Submission / Review Form</p><p>Date Submitted to Highmark: ____/____/____</p><p>Practice or PBIP Name: ______Practice NPI: ______(Required: Please accurately complete your 10-digit #) </p><p>Office Contact Name: ______Title: ______Phone Number: (_____) ______-______Ext.______</p><p>NOTE: Submissions with incomplete or erroneous information will delay review of your submission by the QualityBLUE Submission Committee and could affect your QualityBLUE score.</p><p>Implementation activities are reviewed quarterly. The submissions must be POSTMARK ED on or before the indicated quarterly deadline: November 1 for 1st Quarter February 1 for 2nd Quarter May 1 for 3rd Quarter August 1 for 4th Quarter</p><p>Section 2 Required: eRx Vendor Name, Software Solution, and Software Version </p><p>Please Vendor Name: ______indicate Software Solution: ______selected eRx System: Software Version: ______</p><p>Highmark is a registered mark of Highmark Inc. Blue Shield, and the Shield symbols are registered service marks, and QualityBLUE is a service mark of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.</p><p>Continued on next page</p><p>Highmark Blue Shield V1.0 05/08 Page 1 of 3 Electronic Prescribing (eRx) Initiative Submission Form Date Submitted to Highmark: ____/____/____</p><p>Practice or PBIP Name: ______</p><p>Section 3 Required: Proof of Purchase or Commitment to Purchase eRx System </p><p>Proof of existing eRx system:  Choose One: Proof of commitment to purchase:  Proof of purchase:  Acceptable Documentation: Signature page from Signed Vendor Contract which includes, Please check all both Signatures of eRx Vendor and Practice:  that apply and OR attach copy. Signed Purchase order form: </p><p>Section 4 Required: eRx Software</p><p>Electronically order medications from the patient’s pharmacy of 1.  Verification of choice, record and maintain medication history Functionality: 2. Identify drug-to-drug interactions at point of care  3. Protect confidential patient information  Please check all Direct electronic connections with majority of pharmacies in the functional 4. 49-county area to place prescription orders (faxing capabilities elements that  acceptable) apply to your Communication with the Pharmacy Benefits Manager to show practice’s existing 5. benefits and formulary information at point of care  or purchased eRx Communication with the Pharmacy Benefits Manager to display system. 6. dispensed medications prescribed by other physicians  Bi-directional electronic communications with pharmacies to 7. respond to Pharmacy initiated refill requests  To help with future planning, please tell us if your eRx system is interoperable with an Electronic Health Record (EHR) system? YES  NO </p><p>Continued on next page</p><p>Highmark Blue Shield V1.0 05/08 Page 2 of 3 Electronic Prescribing (eRx) Initiative Submission Form Date Submitted to Highmark: ____/____/____</p><p>Practice or PBIP Name: ______</p><p>Faxes will not be accepted. Please mail this entire form with attachments to: </p><p>Highmark Blue Shield QualityBLUE Submission Review Committee P.O. BOX 535098 Pittsburgh, PA 15253-5098 </p><p>QualityBLUE Submission Review Results – Highmark use only</p><p>Date Received by Highmark: ____/____/_____</p><p>Points Not Review Committee eRx Activity Approved Assigned Approved Date Signature Proof of existing eRx system with minimum functionality (functional 3 elements 1-4), not upgraded with full functionality/bidirectional elements 1-7. Proof of commitment to purchase or proof of purchased eRx system with 3 minimum functionality (functional elements 1-4). Proof of purchased eRx system with full functionality including bidirectional 5 (functional elements 1-7).</p><p>Additional Committee Notes: ______</p><p>Highmark Blue Shield V1.0 05/08 Page 3 of 3 Electronic Prescribing (eRx) Initiative Submission Form</p>