Pharmacy Reimbursement Appeal Form

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

 

Contact Information

 
 
 
Phone
 
 

Pharmacy Information

 
 
 

 

Pharmacy Benefit Manager (PBM) Information

 
 
 
 
 

 

Ground for Appeal(s)

 

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

 

 

Supporting Documentation 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.
Drop your files here