Pharmacies

Basic Claim Transmission | Participating Pharmacy Agreement | Pharmacy Services Manual | Drug Formulary | Prior Authorization Form

Basic Claim Transmission

Pharmacy Payor Sheet (Adobe Acrobat Reader is needed to see this file)

Participating Pharmacy Agreement

Participating Pharmacy Agreement (Adobe Acrobat Reader is needed to see this file)

Pharmacy Services Manual

To obtain copy of PharmAvail Pharmacy Services Manual, please contact PharmAvail:
customerservice@pharmavailbenefits.com or 800-933-3734

Drug Formulary

Formulary List (Adobe Acrobat Reader is needed to see this file)

Prior Authorization Form

Drug Prior Authorization Form (Adobe Acrobat Reader is needed to see this file)

direct member reimbursement form

Direct Member Reimbursement Form (Adobe Acrobat Reader is needed to see this file)