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Payer Sheets
Medicare Part D
611 KMHP AMHP Payer Sheet (PDF)
619 SCHA MAPD Payer Sheet (PDF)
619 SCHA Payer Sheet (PDF)
729 Fresenius Payer Sheet (PDF)
802 Troy Health Plan Payer Sheet (PDF)
809 SCDC Special Needs Plans Payer Sheet (PDF)
815 AmeriHealth Caritas VIP Next Payer Sheet (PDF)
816 AmeriHealth Caritas Florida Payer Sheet (PDF)
Non-Part D
194 ACPA Payer Sheet (PDF)
194 Keystone First Payer Sheet (PDF)
218 Select Health of SC Payer Sheet (PDF)
397 Contra Costa Payer Sheet (PDF)
603 ACLA Payer Sheet (PDF)
618 South Country Health Alliance Payer Sheet (PDF)
621 Blue Cross Complete Payer Sheet (PDF)
628 AmeriHealth Caritas DC Payer Sheet (PDF)
630 San Francisco Health Plan Payer Sheet (PDF)
632 Alameda Payer Sheet (PDF)
636 Alameda Group Care Payer Sheet (PDF)
740 NextGen Healthcare (HSI) Payer Sheet (PDF)
763 ACFC CHC Payer Sheet (PDF)
763 KF CHC Payer Sheet (PDF)
771 AmeriHealth Caritas Delaware Payer Sheet (PDF)
774 Ascella Health Payer Sheet (PDF)
786 PHP Care Preferred Payer Sheet (PDF)
808 AmeriHealth Caritas NC Exchange Payer Sheet (PDF)
811 Trillium Health Resources Payer Sheet (PDF)
812 AmeriHealth Caritas Delaware Exchange Payer Sheet (PDF)
813 AmeriHealth Caritas Florida Exchange Payer Sheet (PDF)
814 AmeriHealth Caritas South Carolina Exchange Payer Sheet (PDF)
AmeriHealth Caritas NH Payer Sheet (PDF)
AmeriHealth Casualty Payer Sheet (PDF)
Medicare-Medicaid
648 Partners Health Plan Payer Sheet (PDF)
650 AmeriHealth VIP Care Plus Payer Sheet (PDF)
651 Select Health First Choice VIP Care Plus Payer Sheet (PDF)
801 AmeriHealth Caritas North Carolina Payer Sheet (PDF)
Misc.
Vaccine Admin Payer Sheet (PDF)
Formulary Files
For a full list of preferred drugs, please refer to your health plan's website.
2025 Specialty Drug List (PDF)
Pharmacy Provider Manual
2025 PerformRx Pharmacy Provider Manual (PDF)
Drug Info Updates
2025
February 2025 (PDF)
January 2025 (PDF)
2024
December 2024 (PDF)
November 2024 (PDF)
October 2024 (PDF)
September 2024 (PDF)
August 2024 (PDF)
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2023
December 2023 (PDF)
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2022
December 2022 (PDF)
November 2022 (PDF)
October 2022 (PDF)
September 2022 (PDF)
August 2022 (PDF)
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April 2022 (PDF)
March 2022 (PDF)
February 2022 (PDF)
January 2022 (PDF)
Pharmacy Appeals
Tennessee
Standard Pharmacy Reimbursement Appeal Form (Tennessee) (PDF)