Tennessee Wholesale and Manufacturer Information

In accordance with TN Rule 0780-01-95-.03(2)(k), a PBM must request the name of the pharmacy’s wholesaler or manufacturer, as applicable, from which the pharmacy purchased the drug or medical product or device at issue as part of its processing of claims for reimbursement from pharmacies.

NCPDP version D.0 does not provide a customizable field to submit this information with the claim electronically.  A process has been created for pharmacies to submit their wholesaler information for claims that have been submitted for reimbursement.

Please complete all fields in the PHARMACY WHOLESALER INFORMATION FORM and submit via email MACappeals@rxipm.com or by fax 800-476-2691.

All fields are required.