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Pharmacy
User: Visitor May 18, 2012
Pharmacy Images
Provider Help Desk: (p) 888-420-9711 (f) 800-408-1088 | Member Help Desk: (p) 866-796-2463 (f) 207-287-8601
Prior Authorization (PA) Helpdesk (for Provider PA inquiries): (p) 888-445-0497 (f) 888-879-6938

Forms

MEPARTD Manual Claim Form NCPDP D.0 MEPARTD Manual Claim Form NCPDP D.0 2/27/2012 170 kB
MEPOP Manual Claim Form NCPDP D.0 MEPOP Manual Claim Form NCPDP D.0 2/27/2012 170 kB
ME Compound ManualClaim Form NCPDP D.0 ME Compound ManualClaim Form NCPDP D.0 2/27/2012 161 kB
SMAC Submittal Form SMAC Submittal Form 8/9/2011 63 kB
MEPOP Adjustment/Supplemental Payment Form MEPOP Adjustment/Supplemental Payment Form 12/23/2010 40 kB
SMAC Research Request Form SMAC Research Request Form 11/24/2010 68 kB
Paper Claim Form MePart-D Paper Claim Form MePart-D 12/23/2010 66 kB
BMS012 Form BMS012 Form 12/23/2010 65 kB