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Effective Date: 




Update: 3/2020



This form is used by managed care organization (MCO) staff to provide updates or corrections to the managed care pharmacy resources available at, 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.


Detailed Instructions

  • 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