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Welcome to the Magellan Medicaid Administration

Medicaid Provider Portal

Magellan Medicaid Administration Provider Portal MMA Provider Portal
340B Information
Item Last Modified
340B Cover Letter 02/23/2022
340B FAQs 02/23/2022
340B Non-participation Notice Form 02/23/2022
340B Participation Notice Form 02/23/2022
Manuals
Item Last Modified
Pharmacy Provider Billing Manual 01/19/2022
Trading Partners FTP Instructions 05/29/2018
MEUPS Provider Sign-in Instructions 06/25/2014
Web Claim Submission (WCS) User Guide 06/27/2014
Payer Specs
Item Last Modified
D.0 Payer Specs 08/27/2020
Drug Lists
Item Last Modified
Diabetic Supply Preferred Drug List Current
Contacts
  • Prior Authorization
    1-800-477-3071
  • Claim Inquiry
    1-800-432-7005

Please note questions regarding claims prior to October 5, 2010 should be directed to 1-800-807-1232.

Provider Notices
Title Description Last Modified
Pharmacy Provider Notice #274 Quantity Limits added to Disposable Diabetic Pumps and Components and Criteria for Continuous Glucose Meters (CGMs) 06/06/2022
Pharmacy Provider Notice #272 New Omnipod NDCs Added to the Diabetic Supply List 05/04/2022
Pharmacy Provider Notice #258 September 2021 PDL and Diabetic Supply List Changes 11/02/2021
Pharmacy Provider Notice #253 BD Diabetic Supplies 03/24/2021
Pharmacy Provider Notice #249 Diabetic Supplies 12/01/2020
Drug Management Review Advisory Board
Item Last Modified
Information about the Drug Management Review Advisory Board External URL
Education
Title Description Last Modified
NCPDP D.0 FAQs Kentucky Medicaid's Frequently Asked Questions 11/14/2011
NCPDP Resources
Title Description Last Modified
https://www.ncpdp.org NCPDP Website - To purchase implementation guides and access technical questions 11/11/2010
CMS Resources
Title Description Last Modified
https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/Versions5010andD0 CMS Website - Central Version 5010 and D.0 Webpage 04/28/2021
http://www.cms.gov/MFFS5010D0 CMS Website - Dedicated HIPAA 5010/D.0 Project Web Page 11/11/2010
Current Notices
Title Description Notice Date
Fee-for-Service Pharmacy Provider Notice #315 September PDL Provider Notice 11/14/2023
Fee-for-Service Pharmacy Provider Notice #314 Member Eligibility Issue 10/17/2023
Fee-for-Service Pharmacy Provider Notice #313 Brixadi PDL Addition and Incentive Fee 10/09/2023
Fee-for-Service Pharmacy Provider Notice #312 Physician Protocol for COVID-19 Test Kits REMINDER 10/04/2023
Fee-for-Service Pharmacy Provider Notice #311 Synagis 09/26/2023
Fee-for-Service Pharmacy Provider Notice #310 Opioid Antagonist Provider Protocol and OTC Naloxone Coverage 09/05/2023
Fee-for-Service Pharmacy Provider Notice #309 FFS Vaccine Coverage Reminder 08/30/2023
Fee-for-Service Pharmacy Provider Notice #308 PHE Unwinding Medicaid Renewal Reminder 07/19/2023
Fee-for-Service Pharmacy Provider Notice #307 May 2023 P&T PDL Changes 07/10/2023
Fee-for-Service Pharmacy Provider Notice #306 Public Health Emergency Unwinding Reminder 06/21/2023
Fee-for-Service Pharmacy Provider Notice #305 OTC List Changes 06/09/2023
Fee-for-Service Pharmacy Provider Notice #304 Drug Shortage Bypass Removal 05/30/2023
Fee-for-Service Pharmacy Provider Notice #303 Akorn Pharmaceuticals Recall 05/17/2023
Fee-for-Service Pharmacy Provider Notice #302 Insulin Glargine Reminder 05/15/2023
Fee-for-Service Pharmacy Provider Notice #301 March 2023 PDL Changes 05/08/2023
Fee-for-Service Pharmacy Provider Notice #300 Makena Market Withdrawal 04/10/2023
Fee-for-Service Pharmacy Provider Notice #299 Routine PDL Changes 03/16/2023
Fee-for-Service Pharmacy Provider Notice #298 KASPER System Outage 03/15/2023
Fee-for-Service Pharmacy Provider Notice #297 Testosterone Pump PDL Change 03/14/2023
Fee-for-Service Pharmacy Provider Notice #296 Drug Shortage Bypass Reminder 03/14/2023
Fee-for-Service Pharmacy Provider Notice #295 Paxlovid Protocol No Longer Active 03/08/2023
Fee-for-Service Pharmacy Provider Notice #294 Drug Shortage Bypass 02/20/2023
Fee-for-Service Pharmacy Provider Notice #293 Further Extension of Temporary PDL Changes Due to Shortages 02/08/2023
Fee-for-Service Pharmacy Provider Notice #292 Lidocaine Patch PDL Update 02/02/2023
Fee-for-Service Pharmacy Provider Notice #291 Further Extension of Temporary PDL Changes Due to Shortages 01/30/2023
Fee-for-Service Pharmacy Provider Notice #290 Further Extension of Temporary PDL Changes Due to Shortages 01/12/2023
Fee-for-Service Pharmacy Provider Notice #289 Preferred Drug List (PDL) Changes 01/11/2023
Fee-for-Service Pharmacy Provider Notice #288 November 2022 P&T PDL Changes 01/09/2023
Fee-for-Service Pharmacy Provider Notice #287 Temporary PDL Changes Due to Shortages Extended 01/04/2023
Fee-for-Service Pharmacy Provider Notice #286 Temporary PDL Changes Due to Shortages 12/31/2022
Fee-for-Service Pharmacy Provider Notice #285 Immune Globulins (IVIG, SCIG) Criteria Change 12/08/2022
Fee-for-Service Pharmacy Provider Notice #284 Brand/ Generic Insulin Changes 11/21/2022
Fee-for-Service Pharmacy Provider Notice #283 September 2022 PDL Changes 11/01/2022
Fee-for-Service Pharmacy Provider Notice #282 Suboxone Incentive Fee Changes 10/05/2022
Fee-for-Service Pharmacy Provider Notice #281 Synagis Update 09/22/2022
Fee-for-Service Pharmacy Provider Notice #280 ProAir HFA Discontinuation 09/20/2022
Fee-for-Service Pharmacy Provider Notice #279 Paxlovid Physician Protocol 08/16/2022
Fee-for-Service Pharmacy Provider Notice #278 Delivery Requirements 08/08/2022
Fee-for-Service Pharmacy Provider Notice #277 Naloxone Treatment Physician Protocol 08/08/2022
Fee-for-Service Pharmacy Provider Notice #276 May 2022 P&T PDL Changes 07/01/2022
Fee-for-Service Pharmacy Provider Notice #275 Generic Truvada Criteria Removal 06/06/2022
Fee-for-Service Pharmacy Provider Notice #274 Quantity Limits Added to Disposable Pumps and CGMs 06/06/2022
Fee-for-Service Pharmacy Provider Notice #273 Lidoderm Shortage Leads to Temporary PDL Changes 05/06/2022
Fee-for-Service Pharmacy Provider Notice #272 New Omnipod NDCs Added to the Diabetic Supply List 05/04/2022
Fee-for-Service Pharmacy Provider Notice #271 March 2022 PDL Changes 05/02/2022
Fee-for-Service Pharmacy Provider Notice #270 MetroCream Shortage 04/25/2022
Fee-for-Service Pharmacy Provider Notice #269 Injectable Drug List 04/04/2022
Fee-for-Service Pharmacy Provider Notice #268 Physician Protocol for COVID-19 Test Kits 02/01/2022
Fee-for-Service Pharmacy Provider Notice #267 COVID-19 Home Test Kits 01/28/2022
Fee-for-Service Pharmacy Provider Notice #266 Brand/Generic Switches 01/25/2022
Fee-for-Service Pharmacy Provider Notice #265 Brand/Generic Reversal 01/14/2022
Fee-for-Service Pharmacy Provider Notice #264 Zoloft Oral Concentrate Update 01/05/2022
Fee-for-Service Pharmacy Provider Notice #263 November 2021 PDL and OTC List Changes 01/03/2022
Fee-for-Service Pharmacy Provider Notice #262 Trulicity/Ozempic Switch 12/21/2021
Fee-for-Service Pharmacy Provider Notice #261 Zoloft Oral Concentrate 12/16/2021
Fee-for-Service Pharmacy Provider Notice #260 Antidepressants 12/14/2021
Fee-for-Service Pharmacy Provider Notice #259 Emergency Declaration Early Refill Bypass 12/13/2021
Fee-for-Service Pharmacy Provider Notice #258 September 2021 PDL and Diabetic Supply List Changes 11/02/2021
Fee-for-Service Pharmacy Provider Notice #257 May 2021 PDL Changes 07/01/2021
Fee-for-Service Pharmacy Provider Notice #256 Senate Bill 51 and Support Act 06/11/2021
Fee-for-Service Pharmacy Provider Notice #255 OTC Drug List Update 06/01/2021
Fee-for-Service Pharmacy Provider Notice #254 March 2021 PDL Changes 05/01/2021
Fee-for-Service Pharmacy Provider Notice #253 BD Diabetic Supplies 03/24/2021
Fee-for-Service Pharmacy Provider Notice #252 COVID-19 Vaccine Updated Fees 03/23/2021
Fee-for-Service Pharmacy Provider Notice #251 November 2020 PDL Changes 01/22/2021
Fee-for-Service Pharmacy Provider Notice #250 COVID-19 Vaccine 01/04/2021
Fee-for-Service Pharmacy Provider Notice #249 Diabetic Supply Changes 12/01/2020
Fee-for-Service Pharmacy Provider Notice #248 Single PDL Changes 11/06/2020
Fee-for-Service Pharmacy Provider Notice #247 September 2020 PDL Changes 11/06/2020
Fee-for-Service Pharmacy Provider Notice #246 NCPDP Quantity Prescribed Update 09/02/2020
Fee-for-Service Pharmacy Provider Notice #245 May 2020 PDL Changes 07/23/2020
Fee-for-Service Pharmacy Provider Notice #244 Brand/Generic Switches 05/07/2020
Fee-for-Service Pharmacy Provider Notice #243 Presumptive Eligible Members 05/07/2020
Fee-for-Service Pharmacy Provider Notice #242 Reimbursement Error for Brand over Generic Products 03/26/2020
Fee-For-Service Pharmacy Provider Notice #241 COVID-19 Emergency Signature Log Change 03/26/2020
Fee-for-Service Pharmacy Provider Notice #240 November 2019 PDL Changes 01/27/2020
Fee-for-Service Pharmacy Provider Notice #239 340B Procedures 12/19/2019
Fee-for-Service Pharmacy Provider Notice #238 September 2019 PDL Changes 11/07/2019
Fee-for-Service Pharmacy Provider Notice #237 Pharmacy License Update Reminder 07/19/2019
Fee-for-Service Pharmacy Provider Notice #236 May 2019 PDL Changes 07/19/2019
Fee-for-Service Pharmacy Provider Notice #235 March 2019 PDL Changes 05/06/2019
Fee-for-Service Pharmacy Provider Notice #234 Updated Buprenorphine-Naloxone PA Waiver 03/04/2019
Fee-for-Service Pharmacy Provider Notice #233 November 2018 PDL Changes 02/06/2019
Fee-for-Service Pharmacy Provider Notice #232 September 2018 PDL Changes 01/03/2019
Fee-for-Service Pharmacy Provider Notice #231 Buprenorphine PA Waiver 10/11/2018
Fee-for-Service Pharmacy Provider Notice #230 Opioid Class Criteria Changes 09/04/2018
Fee-for-Service Pharmacy Provider Notice #229 May 2018 PDL Changes 09/04/2018
Fee-for-Service Pharmacy Provider Notice #228 Pharmacy License Update Reminder 09/04/2018
Fee-for-Service Pharmacy Provider Notice #227 Opioid Class Criteria Changes 06/15/2018
Fee-for-Service Pharmacy Provider Notice #226 March 2018 PDL Changes 06/15/2018
Fee-for-Service Pharmacy Provider Notice #225 November 2017 PDL Changes 06/01/2018
Fee-for-Service Pharmacy Provider Notice #224 May 2017 PDL Changes 06/01/2018
Title Last Modified
Universal PA Request Form – All Others 10/07/2021

For telephonic prior authorization requests or inquiries regarding a prior authorization please call (800) 477-3071.

Please fax prior authorization requests to one of the following numbers —

Regular Fax Line:
800-365-8835
Urgent Requests:
800-421-9064
Nursing Facility:
800-453-2273
Mental Health Drugs:
800-453-2273
Denials and Appeals
  • Only a patient or family member can appeal a prior authorization denial
  • The member has 30 days from receipt of the denial letter to submit a written appeal to the address below:
    • Kentucky Department for Medicaid Services
      Division of Administration and Financial Management
      Administrative Services Branch, 6W-C
      275 East Main Street
      Frankfort, KY 40621-0001
  • The prescribing physician can attend the appeal hearing and testify on the patient’s behalf
Pharmacy and Therapeutics Advisory Committee
Item Last Modified
Information about the Pharmacy and Therapeutics Advisory Committee External URL
P & T Class Schedule 04/06/2023
P & T Member List 02/09/2023
Forms
Item Last Modified
P & T Speaker Request Form - PDF 01/11/2022
P & T Speaker Request Form - Word 01/11/2022
This Year’s Meetings
Meeting Date Agenda Options Committee Recommendations Commissioner's Final Decisions
November 16, 2023 Agenda Options Committee Recommendations Commissioner's Final Decisions
September 21, 2023 Agenda Options Committee Recommendations Commissioner's Final Decisions
May 18, 2023 Agenda Options Committee Recommendations Commissioner's Final Decisions
March 16, 2023 Agenda Options Committee Recommendations Commissioner's Final Decisions
Previous Year’s Meetings
Meeting Date Agenda Options Committee Recommendations Commissioner's Final Decisions
November 17, 2022 Agenda Options Committee Recommendations Commissioner's Final Decisions
September 15, 2022 Agenda Options Committee Recommendations Commissioner's Final Decisions
May 19, 2022 Agenda Options Committee Recommendations Commissioner's Final Decisions
March 17, 2022 Agenda Options Committee Recommendations Commissioner's Final Decisions
Directions
Title Last Modified
Capitol Annex Directions 06/09/2014
Frankfort, KY Map 04/26/2010
Pharmacy and Therapeutics Advisory Committee Archives
Meeting Date Agenda Options Committee Recommendations Commissioner's Final Decisions
November 18, 2021 Agenda Options Committee Recommendations Commissioner's Final Decisions
September 30, 2021 Agenda Options Committee Recommendations Commissioner's Final Decisions
May 20, 2021 Agenda Options Committee Recommendations Commissioner's Final Decisions
March 18, 2021 Agenda Options Committee Recommendations Commissioner’s Final Decisions
Meeting Date Agenda Options Committee Recommendations Commissioner's Final Decisions
November 19, 2020 (Special Called Meeting) Agenda Options Committee Recommendations Commissioner's Final Decisions
September 17, 2020 (Special Called Meeting) Agenda Options Committee Recommendations Commissioner's Final Decisions
May 21, 2020 (Special Called Meeting) Agenda Options Committee Recommendations Commissioner's Final Decisions
March 19, 2020 Agenda Options Cancelled Cancelled
November 21, 2019 Last Modified
Agenda 10/29/2019
Options 10/29/2019
Commissioner’s Final Decisions 12/11/2019
Committee Recommendations 12/11/2019
September 19, 2019 Last Modified
Agenda 08/29/2019
Options 08/29/2019
Commissioner’s Final Decisions 09/27/2019
Committee Recommendations 09/27/2019
May 16, 2019 Last Modified
Agenda 04/30/2019
Options 04/30/2019
Commissioner’s Final Decisions 06/10/2019
Committee Recommendations 06/10/2019
March 21, 2019 Last Modified
Agenda 03/05/2019
Options 03/05/2019
Commissioner’s Final Decisions 04/10/2019
Committee Recommendations 04/10/2019
November 15, 2018 Last Modified
Agenda 10/29/2018
Options 10/29/2018
Commissioner’s Final Decisions 01/04/2019
Committee Recommendations 01/04/2019
September 20, 2018 Last Modified
Agenda 09/04/2018
Options 09/04/2018
Commissioner’s Final Decisions 11/01/2018
Committee Recommendations 11/01/2018
May 17, 2018 Last Modified
Agenda 05/03/2018
Options 05/07/2018
Commissioner’s Final Decisions 06/15/2018
Committee Recommendations 06/01/2018
March 15, 2018 Last Modified
Agenda 02/26/2018
Options 02/26/2018
Commissioner’s Final Decisions 04/05/2018
Committee Recommendations 04/05/2018
November 16, 2017 Last Modified
Agenda 11/02/2017
Options 11/02/2017
Commissioner’s Final Decisions 12/27/2017
Committee Recommendations 12/27/2017
September 21, 2017 Last Modified
Agenda 09/12/2017
Options 09/12/2017
Commissioner’s Final Decisions 12/01/2017
Committee Recommendations 11/15/2017
May 18, 2017 Last Modified
Agenda 04/28/2017
Options 04/28/2017
Commissioner’s Final Decisions 11/15/2017
Committee Recommendations 11/15/2017
March 16, 2017 Last Modified
Agenda 03/16/2017
Options 03/16/2017
Commissioner’s Final Decisions 11/15/2017
Committee Recommendations 11/15/2017
November 17, 2016 Last Modified
Agenda 11/04/2016
Options 11/04/2016
Commissioner’s Final Decisions 11/15/2017
Committee Recommendations 11/15/2017
September 15, 2016 Last Modified
Agenda 08/23/2016
Options 08/23/2016
Commissioner’s Final Decisions 11/15/2017
Committee Recommendations 11/15/2017
May 19, 2016 Last Modified
Agenda 05/10/2016
Options 05/10/2016
Commissioner’s Final Decisions 11/15/2017
Committee Recommendations 11/15/2017
March 17, 2016 Last Modified
Agenda 03/04/2016
Options 03/04/2016
Committee Recommendations 01/11/2017
Commissioner’s Final Decisions 01/11/2017
January 21, 2016 Last Modified
Agenda 01/21/2016
Options 01/21/2016
Committee Recommendations 01/11/2017
Commissioner’s Final Decisions 01/11/2017
November 19, 2015 Last Modified
Agenda 05/10/2016
Options 05/10/2016
Commissioner’s Final Decisions from November 19, 2015 05/10/2016
Cancelled due to lack of quorum N/A
September 17, 2015 Last Modified
Agenda 08/28/2015
Options 08/28/2015
Commissioner’s Final Decisions from September 17, 2015 01/06/2016
Cancelled due to lack of quorum N/A
July 16, 2015 Last Modified
Agenda 06/30/2015
Options 06/30/2015
Commissioner’s Final Decisions from July 16, 2015 09/16/2015
May 21, 2015 Last Modified
Agenda 05/05/2015
Options 05/05/2015
Commissioner’s Final Decisions from May 21, 2015 07/28/2015
Cancelled due to lack of quorum N/A
March 19, 2015 Last Modified
Commissioner’s Final Decisions from March 19, 2015 04/21/2015
Cancelled due to lack of quorum N/A
January 15, 2015 Last Modified
Commissioner’s Final Decisions from January 15, 2015 02/25/2015
Cancelled due to lack of quorum N/A
November 20, 2014 Last Modified
Agenda 11/06/2014
Options 11/06/2014
Commissioner’s Final Decisions from November 20, 2014 12/16/2014
Cancelled due to lack of quorum N/A
September 18, 2014 Last Modified
Agenda 09/18/2014
Options 09/18/2014
Commissioner’s Final Decisions from September 18, 2014 10/20/2014
Cancelled due to lack of quorum N/A
July 17, 2014 Last Modified
Agenda 07/17/2014
Options 07/17/2014
Cancelled due to lack of quorum N/A
May 15, 2014 Last Modified
Cancelled due to lack of quorum N/A
March 20, 2014 Last Modified
Agenda 02/28/2014
Options 02/28/2014
Committee Recommendations 03/26/2014
Commissioner’s Final Decisions from March 20, 2014 03/26/2014
January 16, 2014 Last Modified
Cancelled due to lack of quorum N/A
November 21, 2013 Last Modified
Agenda 10/31/2013
Options 10/31/2013
Committee Recommendations 11/27/2013
Commissioner’s Final Decisions from November 21, 2013 02/03/2014
September 19, 2013 Last Modified
Agenda 08/30/2013
Options 08/30/2013
Committee Recommendations 09/23/2013
Commissioner’s Final Decisions from September 19, 2013 12/10/2013
July 18, 2013 Last Modified
Cancelled due to lack of quorum N/A
May 16, 2013 Last Modified
Cancelled due to lack of quorum N/A
March 21, 2013 Last Modified
Agenda 03/05/2013
Options 03/11/2013
Committee Recommendations 03/27/2013
Commissioner’s Final Decisions from March 21, 2013 07/05/2013
January 17, 2013 Last Modified
Agenda 12/27/2012
Options 12/27/2012
Cancelled due to lack of quorum N/A
November 15, 2012 Last Modified
Agenda 10/30/2012
Options 10/30/2012
Committee Recommendations 11/21/2012
Commisioner's Final Decisions from November 15, 2012 01/08/2013
September 20, 2012 Last Modified
Cancelled due to lack of quorum N/A
July 19, 2012 Last Modified
Agenda 06/27/2012
Options 06/27/2012
Committee Recommendations 07/24/2012
Commisioner's Final Decisions from July 19, 2012 08/20/2012
May 17, 2012 Last Modified
Cancelled due to lack of quorum N/A
March 15, 2012 Last Modified
Agenda 02/27/2012
Options 02/27/2012
Committee Recommendations 03/20/2012
Secretary's Final Decisions from March 15, 2012 04/24/2012
January 19, 2012 Last Modified
Agenda 01/05/2012
Options 01/05/2012
Cancelled due to lack of quorum N/A
November 17, 2011 Last Modified
Cancelled due to lack of quorum N/A
Agenda 11/02/2011
Options 11/02/2011
September 15, 2011 Last Modified
Cancelled due to lack of quorum N/A
Agenda 08/30/2011
Options 08/30/2011
July 21, 2011 Last Modified
Agenda 07/06/2011
Options 07/06/2011
Committee Recommendations 07/25/2011
Secretary's Final Decisions from July 21, 2011 08/26/2011
May 19, 2011 Last Modified
Agenda 05/02/2011
Options 05/02/2011
Committee Recommendations 05/24/2011
Secretary's Final Decisions from May 19, 2011 06/27/2011
March 17, 2011 Last Modified
Agenda 02/28/2011
Options 02/28/2011
Committee Recommendations 03/23/2011
Secretary's Final Decisions from March 17, 2011 04/26/2011
January 20, 2011 Last Modified
Cancelled due to lack of quorum N/A
Agenda 01/05/2011
Options 01/05/2011
November 18, 2010 Last Modified
Agenda 11/01/2010
Options 11/01/2010
Committee Recommendations 11/24/2010
Secretary's Final Decisions from November 18, 2010 01/05/2011
September 16, 2010 Last Modified
Agenda 09/01/2010
Options 09/01/2010
Committee Recommendations 09/22/2010
Secretary's Final Decisions from September 16, 2010 10/28/2010
Speaker Request Form 09/01/2010
July 15, 2010 Last Modified
Cancelled due to lack of quorum N/A
Agenda 06/28/2010
Options 06/28/2010
May 20, 2010 Last Modified
Agenda 05/05/2010
Options 05/05/2010
Committee Recommendations 05/27/2010
Secretary's Final Decisions from May 20, 2010 06/28/2010
Speaker Request Form 05/05/2010
March 18, 2010 Last Modified
Agenda 03/03/2010
Options 03/03/2010
Committee Recommendations 03/24/2010
Secretary's Final Decisions from March 18, 2010 05/19/2010
Speaker Request Form 03/03/2010

Electronic Remittance Advice (ERA) Information

Magellan Medicaid Administration has provided a website to satisfy the CAQH Committee Operating Rules for Information Exchange (CORE) mandate requiring online capability for Electronic Remittance Advice (ERA) enrollment. The form can be completed and electronically submitted via the web portal at https://eftera.magellanrx.com.

Additionally, paper Electronic Remittance Advice (ERA) enrollment forms have been revised in order to satisfy the CAQH Committee Operating Rules.

Electronic Remittance Advice (ERA)

To submit a request to receive an Electronic Remittance Advice (ERA) via the website go to https://eftera.magellanrx.com.
Electronic Remittance Advice (ERA) Help Document with Instructions

If you prefer to submit a paper form to receive an Electronic Remittance Advice (ERA) you can access the form and instructions here — ERA Paper Form (with Instructions & FAQ).

Note: If you would like to receive a paper Remittance Advice please contact Pharmacy Networks Services at 800-441-6001.