Pharmacy Reimbursement Appeal Form

Pharmacy Reimbursement Appeal Form

Pursuant to Tenn. Code Ann. § 56-7-3206(c)(2)(D)

Contact Information

Contact Name*

Contact Email Address*

Contact Phone Number*

Phone

Please choose the option that best represents you*

Select

Pharmacy Information

Pharmacy Name*

10-Digit National Provider ID (NPI)*

Pharmacy Benefit Manager (PBM) Information

PBM Name*

Select or enter value

BIN Number*

PBM Control Number (PCN)*

RX Group Number*

Ground for Appeal(s)

Grounds for the Appeal*

Please enter the grounds for the appeal including the

Select

Are you filing a single appeal or bulk appeals?*

If you are filing bulk appeals, you must fill out the bulk appeals submission template for each unique combination of store (NPI), PBM, BIN, PCN, and Rx Group Number.

Bulk Appeals Submission Template Download

Select

Claim Reimbursement Information

Prescription Number*

11-Digit National Drug Code (NDC)*

Drug Name & Strength*

Drug Dispense Date*

Quantity Dispensed*

Total Drug Reimbursement Amount*

The total amount reimbursed on the claim for the drug excluding the dispensing fee.

Example:

PBM Ingredient Amount Paid: $95.00

+ Patient Copay: $5.00

Total Drug Reimbursement Amount: $100.00

Package Size*

The package size (number of units) that the pharmacy purchased the drug product as supported by a copy of the invoice. Please do not include the unit of measure in this field.

Pharmacy's Actual Cost Per Package*

The total cost of the drug package that the pharmacy purchased as supported by a copy of the invoice.

Did the pharmacy receive any discounts, price concessions, or rebates that further reduce the invoice price on or prior to the appeal?*

Select

Pharmacy's Actual Cost Per Package - Net of Discounts*

The pharmacy's best estimate of their actual cost per package net of any discounts, price concessions, or rebates.

Drug Purchase Date*

The purchase date of the product as supported by a copy of the invoice.

Pharmacy Payment Relief Requested*

Enter the amount of additional payment for the drug ingredient cost (i.e., relief) that the pharmacy is requesting from the PBM.

Example:

Total Drug Reimbursement Amount: $150.00

Pharmacy's Actual Drug Ingredient Cost: $160.00

Relief Requested: $10.00

PBM Final Appeal Date*

Enter the date that the pharmacy received the final decision from the PBM on the initial appeal.

Supporting Documentation Upload

File Upload*

If submitting a single appeal, please upload the following:

Copy(s) of your drug purchase invoice.
Copy(s) of the final decision rendered by the PBM on the initial appeal.
If submitting appeals in bulk, please also include the completed copy of the Bulk Appeals Submission Template.
Please only submit the required documents and ensure no PHI is present such as patient name.

Drag and drop files here or

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