Pharmacy Reimbursement Appeal Form
Pursuant to Tenn. Code Ann. ยง 56-7-3206(c)(2)(D)
Please enter the grounds for the appeal including the
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
If submitting a single appeal, please upload the following: