Downloading a Form to Your Computer
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This form is used by managed care organization (MCO) staff to provide updates or corrections to the managed care pharmacy resources available at txvendordrug.com, specifically the:
- Pharmacy MCO Enrollment Chart
- Pharmacy MCO Assistance Chart
- Prescriber MCO Assistance Chart
When to Prepare
- The form is only for use by MCO staff.
- Enrollment Information section:
- Provide the phone number, fax number, email address or website pharmacies use for MCO pharmacy enrollment.
- Provide the phone number or email address pharmacies use for MCO durable medical equipment enrollment.
- Claims Billing section:
- Provide the "BIN Number" (field 1Ø1-A1), "Processor Control Number" (1Ø4-A4), and "Group ID" (field 3Ø1-C1) pharmacy staff use to submit claims to the MCO.
- Call Center section:
- Provide the phone numbers for the pharmacy, prior authorization and member call centers.
MCO staff sends the form to the Vendor Drug Program via email at firstname.lastname@example.org.
- MCO staff with questions should email email@example.com.