Spreadsheet: 95122d1294792206-hyperlink-to-cell-with-shifting-location-payplan
Sheet: PayPlan

PayPlan Information
TPS  Provider ID | ScriptMed  Payplan | Name | Drug | Reject Code | Reject | Action | Comments | ADDRESS_LINE_1 | ADDRESS_LINE_2 | ADDRESS_LINE_3 | CITY | STATE CODE | ZIP | ZIP EXT | PHONE1 | PHONE1 EXT | PHONE2 | PHONE2 EXT | FAX | Column1 | Medical Plan | Billing Type | TAP Medicaid Provider Number | 3rd Party Processor | Affiliation | BIN | PCN | Tax ID | Contact | Contract  ID | Medicaid  IND | Zero  Auth IND | PHYS_NPI REQD_IND | TAP_NPI REQD_IND | AVAILITY PAYER_ID | COUNT PATIENTS | LAST_BILL DATE
 | AAA | AAA |  |  |  |  | ID = 11 digits (9 AAA Member # & 2 Person code)  Group = AAA ~35% off Generic  ~15% off Brand |  |  |  |  |  |  |  | (800) 222-1134 |  |  |  |  |  |  |  |  |  |  | 4336 | AAA
ADEINC | ADEINC | ADMINISTRATIVE ENTERPRISES INC |  |  |  |  |  | 5810 WEST BEVERLY LANE |  |  | GLENDALE | AZ | 85306 | 1800 | 8007622234 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  | GRACE |  | N | N | N | N |  | 1 | 02/08/2006
AET | AET | AETNA | Lupron | 70 | PRODUCT SERVICE NOT COVERED | FORWARD TO AETNA | ALL AETNA UNLESS RX CARVED OUT | 2355 WAUKEGAN ROAD |  |  | DEERFIELD | IL |  |  | 8002386279 |  |  |  |  |  |  | Adjudicated |  |  |  | 610502 | 670000 |  |  |  | N | Y | Y | Y |  | 418 | 04/26/2010
AHP-CHHP | AHPCHHP | ADVOCATE HEALTH PART-CHRIST HOSP | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - PA REQ'D | PO BOX 0546 |  |  | MT. PROSPECT | IL | 60056 | 379 | 8472986000 |  | 8476354158 |  | 8472986002 |  |  | HCFA | 6 |  | ADVOCATE |  |  |  |  | 3322001 | N | N | N | N |  | 4 | [NAME]
AHP-CON | AHPCON | ADVOCATE HEALTH PART-CONDELL | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - PA REQ'D | PO BOX 0546 |  |  | MT PROSPECT | IL | 60056 |  | 8472986000 |  |  |  |  |  |  | HCFA |  |  | ADVOCATE |  |  |  |  |  | N | N | Y | Y |  | 4 | 03/30/2010
AHP-GSHP | AHPGSHP | ADVOCATE HEALTH PART-GOOD SHEPHARD | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - PA REQ'D | PO BOX 0546 |  |  | MT. PROSPECT | IL | 60056 | 430 | 8472986000 |  | 8476354158 |  | 8472986002 |  |  | HCFA | 7 |  | ADVOCATE |  |  |  |  | 3322001 | N | N | N | N |  | 1 | 04/26/2010
AHP-GSPH | AHPGSPH | ADVOCATE HEALTH PART-GOOD SAMARITAN | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - PA REQ'D | PO BOX 0546 |  |  | MT. PROSPECT | IL | 60056 | 443 | 8472986000 |  | 8476354158 |  | 8472986002 |  |  | HCFA | 3 |  | ADVOCATE |  |  |  |  | 3322001 | N | N | N | N |  | 1 | 02/05/2010
AHP-IMHP | AHPIMHP | ADVOCATE HEALTH PART-IL MASONIC | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - PA REQ'D
AHP-LGHP | [NAME] | ADVOCATE HEALTH PART-LUTHERAN GEN | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - PA REQ'D | PO BOX 0546 |  |  | MT. PROSPECT | IL | 60056 | 546 | 8472986000 |  | 8476354158 |  | 8472986002 |  |  | HCFA | 1 |  | ADVOCATE |  |  |  |  | 3322001 | N | N | N | N |  | 2 | 03/22/2010
AHP-SSHP | AHPSSHP | ADVOCATE HEALTH PART-SOUTH SUBURB | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - PA REQ'D | PO BOX 0869 |  |  | MT. PROSPECT | IL | 60056 | 869 | 8472986000 |  | 8476354158 |  | 8472986002 |  |  | HCFA | 2 |  | ADVOCATE |  |  |  |  | 3322001 | N | N | N | N |  | 8 | 04/23/2010
AHP-THP | [NAME] | ADVOCATE HEALTH PART-TRINITY | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - PA REQ'D | PO BOX 0546 |  |  | MT. PROSPECT | IL | 60056 | 377 | 8472986000 |  | 8476354158 |  | 8472986002 |  |  | HCFA | 5 |  | ADVOCATE |  |  |  |  | 3322001 | N | N | N | N |  | 3 | 04/15/2010
ALIDBN | ALLBS | ALLIED BENEFITS SYSTEMS |  |  |  |  |  | PO BOX 909786-60690 |  |  | CHICAGO | IL | 60690 |  | 8002882078 |  | 3129068080 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 03/10/2010
AHCRX | [NAME] | AMERICAN HEALTH CARE |  |  |  |  |  | 2217 PLAZA DRIVE |  |  | ROCKLIN | CA | 95765 |  | 8008728276 |  |  |  | 9167737210 |  |  | Adjudicated |  |  |  | 610118 | AHC |  |  |  | N | N | N | Y |  | 2 | 04/22/2010
AMERSCPT2 | AMSCRPT | AMERISCRIPT |  |  |  |  |  |  |  |  |  |  |  |  | 8006816912 |  |  |  |  |  |  | Adjudicated |  |  |  | 12924 | AMER9999 |  |  |  | N | N | N | Y |  | 8 | [NAME]
CXM-MEDICA | ANTCAID | ANTHEM MEDICAID |  |  |  | M/I PHARMACY NUMBER FOR ASSISTANCE TO RESOLVE THIS CLAIM REJECT GO TO WWW.EXPRESS-SCRIPTS.COM  ---Forward to Curascript | Non-matched pharmacy OR Pharmacy Not Contracted on DOS  VERIFY ESI ELIGIBILITY . If ESI does not recognize patient - FWD to [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Adjudicated |  |  |  | 610053 | 630 |  |  |  | N | N | Y | Y |  | 2 | 07/27/2009
MDI-AHPS | ANTHPS | ANTHEM HEALTH PLAN SELECT HMO |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 11200 |  |  |  | N | N | N | Y |  | 1 | 12/06/2007
APM-HZ | APMHZN | APM-HORIZON BCBS |  |  |  |  |  |  |  |  |  |  |  |  | 8003646331 |  |  |  |  |  |  | Adjudicated |  | APM |  | 4336 | [NAME] |  |  |  | N | N | Y | Y |  | 2 | 01/01/1900
APS-RX | APSRX | APS PHARMACY |  |  |  |  |  |  |  |  |  |  |  |  | 8772777934 |  |  |  |  |  |  | Adjudicated |  |  |  | 610704 | APSRX |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
ARG-DE | ARGBCBS | ARGUS-BCBS OF DE |  |  |  | IF COPAY IS 100%, FWD TO WALGREENS SP |  |  |  |  |  |  |  |  | 8008654018 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 11834 | 3010000 |  |  |  | N | N | N | Y |  | 11 | 11/03/2005
BENEBARD | ARGBEN | BENECARD |  |  |  |  | BenRx group was previously processed thru Argus. BeneCard now handles BenRx claims processing. Argus claims processing still handled by Argus. Same BIN and PCN for both groups |  |  |  |  |  |  |  | BenCard (888) 907-0050 |  | Argus (800) 522-7487 |  |  |  |  | Adjudicated |  | ARG |  | 14179 | 9743 |  |  |  | N | N | Y | Y |  | 5 | 01/01/1900
ARG-BSCA | ARGBSCA | BLUE SHIELD OF CA | Lupron |  | If PPO: Must obtain valid test claim rejection. MD BUY AND BILL | If HMO: Investigate IPA. May be a contracted plan. | MD BUY AND BILL if non-contracted HMO |  |  |  |  |  |  |  | 8005227487 |  |  |  |  |  | BS OF CALIFORNIA | Adjudicated |  | ARG |  | 600428 | 1910000 |  |  |  | N | N | Y | Y |  | 45 | 01/01/1900
CIG | ARGCIG | CIGNA-ARGUS | Lupron | 70 | PRODUCT SERVICE NOT COVERED | Forward to CIGNA TELDRUG | IF CIGNA IS NOT PBM,  IV MUST INVESTIGATE | 2355 WAUKEGAN RD. |  |  | DEERFIELD | IL |  |  | (800) 622-5579 RX (800) 244-6224 MM |  |  |  |  |  | CIGNA | Adjudicated |  | ARG |  | 600428 | 600000 |  |  |  | N | N | Y | Y |  | 327 | 12/26/2007
FUTURE SCR | [NAME] | FUTURE SCRIPTS |  | 70 | PRODUCT SERVICE NOT COVERED -> | FORWARD TO CAREMARK |  |  |  |  |  |  |  |  | 8886787012 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 3820000 |  |  |  | N | N | Y | Y |  | 32 | 01/01/1900
FTRSCRPT1 | ARGFUT1 | FUTURE SCRIPTS |  | 70 | PRODUCT SERVICE NOT COVERED -> | FORWARD TO CAREMARK |  |  |  |  |  |  |  |  | 8886787012 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 3840000 |  |  |  | N | N | Y | Y |  | 4 | 01/01/1900
GEIS | ARGGEIS | GEISINGER HEALTH PLAN | Lupron |  | PAID CLAIM | FORWARD TO CARESITE | WE MAY RECEIVE A PAID CLAIM, BUT WE CAN NO LONGER PROVIDE, CONTRACT TERMINATED | 100 NORTH ACADEMY AVENUE |  |  | DANVILLE | PA | 17822 | 1 | 8005227487 |  | 8009884861 |  | 5712715610 |  | GEISINGER | Adjudicated |  | ARG | GEIS | 600428 | 2040000 |  |  |  | N | N | Y | Y |  | 10 | 10/15/2007
ARG-GHP | ARGGHP | ARGUS-PROVIDENCE |  |  |  |  |  |  |  |  |  |  |  |  | 8772163644 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 1420000 |  |  |  | N | N | N | Y |  | 7 | 01/01/1900
CIG-GW1 | ARGGWE | GREAT WEST HEALTHCARE |  |  |  |  | PS can only fill first fill. Forward to Teldrug |  |  |  |  |  |  | 8 | 8003519170 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 5180000 |  |  |  | N | N | Y | Y |  | 35 | 01/01/1900
CIG-GW2 | ARGGWE2 | GREAT WEST HEALTHCARE |  |  |  |  | PS can only fill first fill. Forward to Teldrug |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 600428 | 5190000
ARG-GATE | ARGGWY | ARGUS-GATEWAY |  | 75 | PRIOR AUTHORIZATION REQUIRED | FORWARD TO WALGREENS/MEDMARK |  |  |  |  |  |  |  |  | 8005227487 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 2710000 |  |  |  | N | N | Y | Y |  | 11 | 01/01/1900
ARGHS | ARGHS | ARGUS-HEALTHSOURCE ME |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 600428 | 00600000
ARG-HUMANA | ARGHUM | ARGUS-HUMANA | Lupron |  |  | FORWARD TO RIGHTSOURCE upon valid reject |  |  |  |  |  |  |  |  | 8008658715 |  |  |  |  |  | HUMANA | Adjudicated |  | ARG |  | 610649 | 3190000 |  |  |  | N | N | N | Y |  | 154 | 01/04/2006
ARG-PA | ARGKEY | [NAME] |  | 70 50 75 | PRODUCT SERVICE NOT COVERED   NON-MATCHED PHARMACY  PRIOR AUTHORIZATION REQUIRED | FORWARD TO ICORE |  | 75 REMITTANCE DR | STE 1017 |  | CHICAGO | IL | 60675 |  | 8005886767 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 1940000 |  |  |  | N | N | Y | Y |  | 15 | 01/01/1900
ARG/L3V | ARGL3V | ARGUS-JR SEPTIC SERVICE |  |  |  |  |  |  |  |  |  |  |  |  | 8005227487 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 3020000 |  |  |  | N | N | Y | Y |  | 3 | 09/20/2005
LVLACE | ARGLOV | LOVELACE HEALTH PLAN |  |  |  |  |  |  |  |  | DEERFIELD | IL | 60051 |  | 8008087363 |  | 5052627917 |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 2494225 |  |  |  | N | N | Y | Y |  | 6 | 01/01/1900
PERFORMNHP | ARGNHP | [NAME] HEALTH |  |  |  |  |  |  |  |  |  |  |  |  | 8669107654 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 5280000 |  |  |  | N | N | Y | Y |  | 2 | 01/01/1900
ARG7 | ARGOPT | ARGUS |  |  |  |  |  |  |  |  |  |  |  |  | 8005227487 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 1730000 |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
ARGOPT | ARGOPT | ARGUS-OPTIMA | Lupron |  |  | FORWARD TO CAREMARK |  |  |  |  |  |  |  |  | 8005227487 |  |  |  |  |  | OPTIMA | Adjudicated |  | ARG |  | 600428 | 1730000 |  |  |  | N | N | Y | Y |  | 38 | 01/01/1900
ARG5 | ARGOPT | ARGUS-SENTARA | Lupron |  |  | FORWARD TO PHARMACARE |  | 2355 WAUKEGAN RD |  |  | DEERFIELD | IL | 60015 |  | 8005227487 |  |  |  |  |  | SENTARA | Adjudicated |  | ARG |  | 600428 | 1730000 |  |  |  | N | N | Y | Y |  | 3 | 01/01/1900
ARG-OR | ARGOR | ARGUS-BCBS OF OR |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 610623 | 2050000
ARG-PH | ARGPH | ARGUS-PRIORITY HEALTH |  |  |  |  |  |  |  |  |  |  |  |  | 8005227487 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 750000 |  |  |  | N | N | Y | Y |  | 14 | 03/08/2004
ARG8 | ARGPRO | ARGUS-PROSPECT |  |  |  |  |  |  |  |  |  |  |  |  | 8884371508 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 610624 | 2080000 |  |  |  | N | N | Y | Y |  | 4 | 08/31/2007
SCRPTGD | ARGSG | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  | 8005227487 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 1990000 |  |  |  | N | N | Y | Y |  | 6 | 01/01/1900
ARG-VIS | ARGVISTA | ARGUS-VISTA |  |  |  |  |  |  |  |  | DEERFIELD | IL | 60015 |  | 8005227487 |  |  |  |  |  |  | Adjudicated |  |  |  | 610631 | 3110000 |  |  |  | N | N | N | Y |  | 9 | 01/01/1900
ASR1 | ASR | ADMINSTRATIVE SERVICE RESEARCH |  |  |  |  |  | PO BOX 6392 |  |  | GRAND RAPIDS | MI | 49516 |  | 8009682449 |  | 6169571751 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 01/01/1900
 | ASSURHLT | ASSURANT HEALTH | Lupron |  |  | Typically covered under MM | MM - Preferred SPPs = Curascript, Accredo, and BioScrip |  |  |  |  |  |  |  | 8008001212 | 6777
AUXIANT750 | [NAME] | AUXIANT |  |  |  |  |  | P.O. BOX 75008 |  |  | CEDAR RAPIDS | IA | 52407 | 5008 | 3193983283 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
BACMG | BAYCMG | BAY AREA COMMUNITY MEDICAL GRP | Lupron |  |  |  | CONTRACT - PA REQ'D | 6029 BRISTOL PARKWAY, SUITE 100 | ATTN: CLAIMS MANAGER | SANTA MONICA BAY PHYS HEALTH SERVICES | CULVER CITY | CA | 90230 |  | 3104175900 |  |  |  | 3104101030 |  |  | HCFA |  |  | SMBPHS |  |  | 954124612 |  | 1913001 | N | N | N | N |  | 3 | 04/08/2010
BCA | BCBSAL | BCBS OF ALABAMA | Lupron |  | WILL RECEIVE FULL COST COPAY, INSURANCE PAYS ZERO | Forward to CURASCRIPT | CHECK FOR CARVED OUT PHARMACY BENEFIT WHEN REJ: PRODUCT NOT COVERED | PO BOX  995 | 450 RIVERCHASE PKWY EAST |  | BIRMINGHAM | AL | 35298 |  | 8002169920 |  |  |  |  |  |  | Adjudicated |  |  |  | 4915 |  | 63-010383 |  |  | N | Y | Y | Y |  | 61 | 04/27/2010
COMCOTEC | BCBSAZ | BCBS OF ARIZONA-COMCOTEC | Lupron | 50   70 | NON-MATCHED  PHARMACY  PRODUCT SERVICE NOT COVERED | MD BUY AND BILL IF NOT COVERED UNDER PHARMACY BENEFIT |  | 2355 WAUKEGAN RD |  |  | DEERFIELD | IL | 60015 |  | 8003251810 |  | 6028644273 |  |  |  | BC/BS OF ARIZONA | Adjudicated |  | SXC |  | 603017 | BAZ |  |  |  | N | N | N | Y |  | 20 | 01/01/1900
BCC | BCBSCA | ANTHEM BLUE CROSS OF CA |  |  |  | M/I PHARMACY NUMBER FOR ASSISTANCE TO RESOLVE THIS CLAIM REJECT GO TO WWW.EXPRESS-SCRIPTS.COM  ---Forward to Curascript | Non-matched pharmacy OR Pharmacy Not Contracted on DOS  VERIFY ESI ELIGIBILITY . If ESI does not recognize patient - FWD to [NAME]
BCC | BCBSCA | BLUE CROSS OF CALIFORNIA (ANTHEM) |  |  |  | M/I PHARMACY NUMBER FOR ASSISTANCE TO RESOLVE THIS CLAIM REJECT GO TO WWW.EXPRESS-SCRIPTS.COM  ---Forward to Curascript | Non-matched pharmacy OR Pharmacy Not Contracted on DOS  VERIFY ESI ELIGIBILITY . If ESI does not recognize patient - FWD to [NAME] | SYSTEMED PHARMACY INC | 4700 ROCKSIDE RD #200 |  | INDEPENDENCE | OH | 44131 | 2155 | 8009627378 |  | 8007002533 |  |  |  |  | Adjudicated |  | PSV |  | 610053 | 7Q 7700570 |  |  |  | N | N | N | N |  | 1 | 01/01/1900
BCBSILXO | BCBSIL | BCBS OF ILLINOIS | Lupron |  |  | USE BCBS VARIABLE PARAGRAPH | CONTRACT - REQUIRES PRE'D | 300 RANDOLPH STREET |  |  | CHICAGO | IL | 60601 | 5099 | 8009728088 |  | 3126536000 |  |  |  | BC/BS OF ILLINOIS - PPO Only | HCFA | 3336C0003X |  | BCBSILXO |  |  | 361236610 |  |  | N | N | N | Y | 621 | 334 | 04/27/2010
013 | BCBSIL1 | BCBS OF ILLINOIS (not contracted - IL is home state) |  |  |  |  |  | P.O. BOX 805107 |  |  | CHICAGO | IL | 60680 | 4112 | 8009728088 |  |  |  |  |  |  | HCFA | 3336C0003X |  |  |  |  | 371241037 |  |  | N | N | N | Y | 621 | 251 | 04/27/2010
BCBSKAN | BCBSKS | BCBS OF KANSAS - PHARMACY |  |  |  |  |  |  |  |  |  |  |  |  | 8778938485 |  |  |  |  |  |  | Adjudicated |  | PRIMTHER |  | 610455 | KSBCS |  |  |  | N | N | N | Y |  | 17 | 03/18/2004
13 | BCBSKS1 | BCBS OF KANSAS - MAJOR MEDICAL |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | HCFA
BCBSMS | BCBSMS | BCBS OF MISSISSIPPI-COMMUNITY PLUS |  |  |  |  |  | P.O. BOX 1043 |  |  | [NAME] | MS | 39215 |  | 8005515258 |  |  |  |  |  |  | Adjudicated |  |  |  | 4583 | HVI |  |  |  | N | N | Y | Y |  | 14 | 04/26/2010
MDI-BCBSMT | BCBSMT | MEDIMPACT BCBS MT |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 36430
BND | BCBSND | BCBS OF N DAKOTA-RX DAKOTA |  |  |  |  |  | C/O PROPAR |  |  | DEERFIELD | IL |  |  | 8008214795 |  |  |  |  |  |  | Adjudicated |  | PPR |  | 610455 | NDBCS |  |  |  | N | N | Y | Y |  | 5 | 04/09/2007
BCBSNM | BCBSNM | BCBS OF NEW MEXICO | Lupron |  |  | USE BCBS VARIABLE PARAGRAPH | CONTRACT - NEED TO CALL (800) 325-8334 opt. 4 ; 6 AND OBTAIN REF# IF THEY SAY NO PA REQ'D. | PO BOX 27630 |  |  | ALBUQUERQUE | NM | 87125 |  | 8883493706 |  | 8883493706 |  |  |  | PPO, POS, HMO, Indemity | HCFA | 3336C0003X |  |  |  |  | 364010023 |  |  | N | N | Y | Y | 790 | 15 | 04/23/2010
BCBSOK | BCBSOK | BCBS OF OKLAHOMA | Lupron |  |  | USE BCBS VARIABLE PARAGRAPH | CONTRACT  CHECK CONTRACT JOB AID | PO BOX 3283 | ATTN:  [NAME]--PHARMACY DEPT |  | TULSA | OK | 74102 | 3283 | 8004965774 |  | 8006722567 |  | 9185512333 |  | PPO & HMO only | HCFA | 3336C0003X |  | BCBSOK |  |  | 346010023 |  |  | N | N | N | Y | 840 | 37 | 04/26/2010
MC21 | BCBSPR | TRIPLE S BCBS OF PR |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 10868 | MC21
APM-PAI2 | BCBSSC | APM-HORIZON BCBS SC |  |  | If excluded under Rx benefits and covered under MM, forward to Caremark |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | BCBS OF SC |  |  |  |  | 4336 | ECFDRX
BCBSTN | BCBSTN | BCBS OF TENNESSEE | Lupron |  |  |  | REQUIRES PRE'D |  |  |  |  |  |  |  | 8009247141 |  |  |  |  |  |  | HCFA | 3336C0003X |  |  |  |  |  |  |  | N | N | Y | Y | 621 | 11 | 04/16/2010
BCBSTX1 | BCBSTX | BSBS OF TEXAS | Lupron |  |  |  | CONTRACT - REQUIRES PRE'D | 901 S. CENTRAL EXPRESSWAY | NORTH BUILDING D | ATTN:  VALERIE SMITH | RICHARDSON | TX | 75080 |  | (800) 451-0287 |  | 9727667905 |  |  |  | PPO & HMO only | HCFA | 3336C0003X |  |  |  |  |  | VALERIE SMITH |  | N | N | N | N | 84980 | 260 | 04/27/2010
WYBCBS | BCBSWY | BCBS OF WYOMING |  |  |  |  |  |  |  |  |  |  |  |  | 8004247094 |  |  |  |  |  |  | Adjudicated |  | PRIMTHER |  | 800001 | WYBCS |  |  |  | N | N | Y | Y |  | 1 | 04/20/2005
BENEFIT-CA | BENADMCA | BENEFIT ADMINISTRATORS |  |  |  |  |  | P.O. BOX 420390 |  |  | SAN FRANCISCO | CA | 94142 |  | 8002536486 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 04/27/2010
BEYON | BEYOND | BEYOND PHARMACY |  |  |  |  |  | P.O. BOX 26546 |  |  | OVERLAND PARK | KS | 66225 |  | 8662479996 |  | 9136610299 |  | 9136610297 |  |  | Adjudicated |  |  |  | 610641 | PB |  |  |  | N | N | N | N |  | 4 | 01/01/1900
AKM | CAIDAK | ALASKA MEDICAID |  |  |  |  |  | PO BOX 240649 |  | FIRST HEALTH SERVICES CORPORATION | ANCHORAGE | AK | 99524 | 649 | 8008843238 | 5 | 8008847387 |  |  |  |  | Adjudicated | PH024IL |  | MEDICAID | 9661 | P013009661 |  |  |  | Y | N | Y | Y |  | 6 | 04/21/2010
ALM | CAIDAL | ALABAMA MEDICAID | Lupron |  |  | FORWARD TO PHARMACARE | UNABLE TO PROVIDE | ****WE CAN NOT PROVIDE******** | ****FWD TO CURASCRIPT**** |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | Y |  | 2 | 01/01/1900
ARMM | CAIDAR | ARKANSAS MEDICAID | Lupron |  |  | FORWARD TO CURASCRIPT |  | *************FORWARD TO CURASCRIPT****** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 4 | 01/01/1900
CAM | CAIDCA | CALIFORNIA MEDICAID | Lupron |  |  | MD BUY AND BILL |  | *********WE CAN NOT PROVIDE****** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 7 | 01/01/1900
COMD | CAIDCO | COLORADO MEDICAID | Lupron |  |  | MD BUY AND BILL |  | ******WE CAN NOT PROVIDE****** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 3 | 01/01/1900
CTM | CAIDCT | CONNECTICUT MEDICAID | Lupron |  |  |  | UNABLE TO PROVIDE | ******  WE CAN NOT PROVIDE ********* |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 6 | 01/01/1900
DEM | CAIDDE | DELAWARE MEDICAID | Lupron |  |  | FORWARD TO CURASCRIPT | UNABLE TO PROVIDE | ********  WE CAN NOT PROVIDE ******** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 01/01/1900
FLM | CAIDFL | FLORIDA MEDICAID | Lupron |  |  |  | IF THRU PRESTIGE -PROCESS UNDER NPS | **** WE CAN NOT PROVIDE***** | FORWARD TO CURASCRIPT |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 21 | 01/01/1900
GAM | CAIDGA | GEORGIA MEDICAID |  |  |  | FORWARD TO PHARMACARE | (PEACH STATE ONLY) FORWARD TO CAREPLUS IN GA-MD MUST CALL FOR PA @ [PHONE] | ******** WE CAN NOT PROVIDE ******* |  |  |  |  |  |  |  |  |  |  |  |  |  | Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 10 | 01/01/1900
IOM | CAIDIA | IOWA MEDICAID |  |  | CAIDIA doesn't cover generic [NAME]; they only cover Aygestin. Process Aygestin |  |  | PO BOX 150001 |  |  | DES MOINES | IA | 50315 |  | 8774637671 |  | 8003388366 |  |  |  |  | Adjudicated | 1326042870 |  | MEDICAID | 11933 | IAPOP | 1466653 |  |  | N | N | Y | Y |  | 15 | 04/27/2010
IDM | CAIDID | IDAHO MEDICAID | Lupron |  |  |  |  | *******WE CAN NOT PROVIDE******* | FORWARD TO CURASCRIPT |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 01/01/1900
ILM | CAIDIL | IL DEPT PUBLIC AID | Lupron |  |  |  |  | PO BOX 19114 |  |  | SPRINGFIELD | IL | 62794 | 9114 | 8002528942 |  | 2177820538 |  | 2177825565 |  |  | Adjudicated | [PHONE] |  | MEDICAID | 8259 | HVI |  |  |  | Y | N | Y | Y |  | 77 | 04/27/2010
INM | CAIDIN | INDIANA MEDICAID |  |  |  |  |  | 2355 WAUKEGAN RD |  |  | DEERFIELD | IL |  |  | 8005771278 |  | 8777075750 |  |  |  |  | Adjudicated | 200897550A |  | MEDICAID | 610467 | INCAIDPROD |  |  |  | Y | N | Y | Y |  | 41 | 04/27/2010
KSM | CAIDKS | KANSAS MEDICAID | Lupron |  |  | FORWARD TO PRECISION RX | UNABLE TO PROVIDE | *****WE CAN NOT PROVIDE****** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 01/01/1900
[NAME] | CAIDKY | KENTUCKY MEDICAID |  |  |  |  |  | UNISYS CORP | PO BOX 2016 |  | FRANKFORT | KY | 40602 | 2016 | 8004327005 |  | 8002054696 |  |  |  |  | Adjudicated | 7100054780 |  | MEDICAID | 11529 | P022011529 |  |  |  | N | N | Y | Y |  | 21 | 04/26/2010
LAM | CAIDLA | LOUISIANA MEDICAID | Lupron |  |  |  | UNABLE TO PROVIDE | FORWARDING TO CURASCRIPT |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 3 | 01/01/1900
MAMD | CAIDMA | MASSACHUSETTS MEDICAID | Lupron |  |  | FORWARD TO PHARMACARE |  | ********* WE CAN NOT PROVIDE ********* |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 5 | 01/01/1900
MDMA | CAIDMD | MARYLAND MEDICAID |  | 110 | M/I Software Vendor/Certification ID | FORWARD TO CAREMARK |  |  |  |  |  |  |  |  | 8009323918 |  | 8667101447 |  |  |  |  | Adjudicated | 416866600 |  | MEDICAID | 610084 | DRMDPROD |  |  |  | Y | N | Y | Y |  | 1 | 03/19/2010
MD/AMERIGP | CAIDMD1 | MARYLAND MEDICAID-AMERIGROUP | Lupron |  |  |  |  |  |  |  |  |  |  |  | 8003455413 |  |  |  |  |  |  | Adjudicated |  |  |  | 610084 | PCS |  |  |  | N | N | Y | Y |  | 26 | 11/19/2009
 | CAIDME | MAINE MEDICAID |  |  |  |  | **** SEE [NAME] ***
MIC | CAIDMI | MICHIGAN MEDICAID | Lupron |  |  | MD BUY AND BILL |  |  |  |  |  |  |  |  | 8776245204 |  | 8049657781 |  | 8049657647 |  |  | Adjudicated | 1466653 |  |  | 9737 | MIMEDICAID |  |  |  | N | N | N | N |  | 3 | 04/06/2005
MNM | CAIDMN | MINNESOTA MEDICAID |  |  |  |  |  | PO BOX 64166 |  | MN MEDICAL ASSISTANCE-MN DEPT HUMAN | ST PAUL | MN | 55164 | 166 | 8003665411 |  |  |  | 6512971273 |  |  | Adjudicated | 222500000 |  | MEDICAID | 610459 |  |  |  |  | Y | N | Y | Y |  | 2 | 04/15/2010
MOSM | CAIDMO | MISSOURI MEDICAID | Lupron |  |  |  |  | ********WE CAN NOT PROVIDE********* | FORWARD TO CURASCRIPT |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 01/01/1900
[NAME] | CAIDMS | MISSISSIPPI MEDICAID | Lupron |  |  |  |  | ********* WE CAN NOT PROVIDE ******* |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 01/01/1900
NCM | CAIDNC | NORTH CAROLINA MEDICAID | Lupron |  |  | FORWARD TO PHARMACARE |  | ******* WE CAN NOT PROVIDE ****** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 9 | 01/01/1900
NDM | CAIDND | NORTH DAKOTA MEDICAID |  |  |  | FORWARD TO CURASCRIPT |  | ******* WE CAN NOT PROVIDE ****** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated
NEM | CAIDNE | NEBRASKA MEDICAID |  |  |  | MD BUY AND BILL |  | ********* WE CAN NOT PROVIDE ******** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 01/01/1900
NHM | CAIDNH | NEW HAMPSHIRE MEDICAID | Lupron |  |  |  |  | *********** WE CAN NOT PROVIDE ******** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 01/01/1900
NJM | CAIDNJ | NEW JERSEY MEDICAID | Lupron |  |  |  |  | ****** WE CAN NOT PROVIDE AS OF 2/6/04 * |  |  |  |  |  |  |  |  |  |  |  |  |  | Adjudicated | 9045708 |  |  | 610515 | [NAME] |  |  |  | N | N | N | N |  | 6 | 06/16/2003
NMM | CAIDNM | NEW MEXICO MEDICAID | Lupron |  |  |  | PA REQ'D |  |  |  |  |  |  |  | 8003654944 |  | 8002997304 | 4 |  |  |  | Adjudicated | 26126702 |  | MEDICAID | 610084 | DRNMPROD |  |  |  | N | N | Y | Y |  | 1 | 12/08/2009
NVM | CAIDNV | NEVADA MEDICAID | Lupron |  |  |  |  | ********* WE CAN NOT PROVIDE ******* |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 01/01/1900
NYM | CAIDNY | NEW YORK MEDICAID | Lupron |  |  |  |  | ********* WE CAN NOT PROVIDE ******* |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 21 | 01/01/1900
OHM | CAIDOH | OHIO MEDICAID | Lupron |  |  | MD BUY AND BILL |  | ***********CANNOT PROVIDE*************** |  |  |  |  |  |  | 8775181545 |  | 8006861516 |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | Y | N | Y | Y |  | 5 | 09/27/2005
OKM | CAIDOK | OKLAHOMA MEDICAID |  |  |  |  |  | 4545 N LINCOLN BLVD | SUITE 124 |  | OKLAHOMA CITY | OK | 73105 | 3413 | 8005220114 |  |  |  |  |  |  | Adjudicated | 200227420A |  | MEDICAID | 10579 | OKAT1 |  |  |  | Y | N | Y | Y |  | 26 | 04/27/2010
ORM | CAIDOR | OREGON MEDICAID | Lupron |  |  |  |  | ******** WE CAN NOT PROVIDE ****** |  |  |  |  |  |  |  |  |  |  |  |  |  | Adjudicated |  |  |  | 14203 | ORDHSFFS |  |  |  | N | N | N | N |  | 5 | 01/01/1900
PAM | CAIDPA | PENNSYLVANIA MEDICAID | Lupron |  | CLAIM HAS NOT BEEN PAID/CAPTURED, SPECIALTY DRUG MUST BE BILLED BY PREFERRED SPECIALTY PROVIDER ACCREDO ([PHONE] OR MEDMARK ([PHONE]). |  |  | DEPARTMENT OF PUBLIC WELFARE | 7TH AND FOSTER STREET | P.O. BOX 8045 | HARRISBURG | PA | 17105 |  | 8005378861 | 5 | 8005378862 | 5 |  |  |  | Adjudicated | [PHONE] |  | MEDICAID | 600760 | 345527167 | 236003113 |  |  | Y | N | Y | Y |  | 16 | 02/25/2010
RIM | CAIDRI | RHODE ISLAND MEDICAID |  |  |  | FORWARD TO PHARMACARE |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated
[NAME] | CAIDSC | SOUTH CAROLINA MEDICAID | Lupron | 75 | PRIOR AUTHORIZATION REQUIRED Rejection for 11.25 Day Supply Exceeded ok to run as 31 days per [NAME] ext. 55418 | (Do not call) OVERRIDE FIELDS:  [NAME] (location code)=01, EU (461)=1,  EV (462)=ELEVEN [NAME] |  |  |  |  |  |  |  |  | 8662541669 |  | 8037887622 |  |  |  |  | Adjudicated | 7I3143 |  | MEDICAID | 9745 | P006009745 |  |  |  | N | N | Y | Y |  | 14 | 04/27/2010
ARG/SCM | CAIDSC1 | SOUTH CAROLINA MEDICAID-ARGUS |  |  |  |  |  |  |  |  |  |  |  |  | 8005227487 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 600428 | 2180000 |  |  |  | N | N | Y | Y |  | 5 | 01/01/1900
TNM-SXC | CAIDTN | TENNESSE MEDICAID-TENNCARE |  |  |  |  |  |  |  |  |  |  |  |  | 8664345520 |  |  |  |  |  |  | Adjudicated |  |  |  | 1553 | TENNCARE |  |  |  | N | N | Y | Y |  | 84 | 04/27/2010
TEXM | CAIDTX | TEXAS MEDICAID |  |  |  | MD BUY AND BILL | Per [NAME], cannot become provider | ********* WE CAN NOT PROVIDE *********** |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 01/01/1900
UTM | CAIDUT | UTAH MEDICAID |  |  |  |  |  | PO BOX 143106 |  |  | SALT LAKE CITY | UT | 84114 | 3106 | 8006629651 |  | 8015386155 |  | 8015386805 |  |  | Adjudicated | 1326042870 |  |  | 610438 |  |  |  |  | Y | N | Y | Y |  | 9 | [NAME]
VAM | CAIDVA | VIRGINIA MEDICAID |  |  |  |  |  | 600 E BROAD ST, STE 1300 |  |  | RICHMOND | VA | 23219 |  | 8008849730 |  | 8049659732 |  |  |  |  | Adjudicated | 1326042870 |  | MEDICAID | 10900 | 5148010900 |  |  |  | Y | N | Y | Y |  | 20 | 04/27/2010
VA-HMO | CAIDVA2 | ARGUS VIRGINIA MEDICAID HMO |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 600428 | 02520000
VTM | CAIDVT | VERMONT MEDICAID | Lupron |  |  |  | FORWARD TO CURASCRIPT | **********WE CAN NOT PROVIDE*********** | FORWARD TO CURASCRIPT |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 01/01/1900
WAM-POP | CAIDWA | WASHINGTON MEDICAID |  |  |  |  |  |  |  |  |  |  |  |  | 8005623022 |  |  |  |  |  |  | Adjudicated | 6031629 |  |  | 610706 | WAPROD |  |  |  | N | N | Y | Y |  | 6 | [NAME]
WIM | CAIDWI | WISCONSIN MEDICAID | Lupron |  |  |  | FORWARD TO PHARMACARE | *********** WE CAN NOT PROVIDE ********* |  |  |  |  |  |  | 8009479627 |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 13 | 01/01/1900
WVM | CAIDWV | WEST VIRGINIA MEDICAID | Lupron |  |  |  | FORWARD TO CURASCRIPT | ************ WE CAN NOT PROVIDE ******* |  |  |  |  |  |  |  |  |  |  |  |  |  | Non- Adjudicated |  |  |  |  |  |  |  |  | N | N | N | N |  | 7 | 01/01/1900
CARE 1ST | CARE1ST | CARE FIRST BCBS | Lupron | 70 | PRODUCT SERVICE NOT COVERED | FORWARD TO WALGREENS/MEDMARK |  |  |  |  |  |  |  |  | 8888504999 |  | 8002413371 |  |  |  | CAREFIRST BC/BS OF MD | Adjudicated |  | ARG |  | 11834 | 3000000 |  |  |  | N | N | Y | Y |  | 73 | 09/16/2005
RXA/CRS 2 | CARESMI | CARESOURCE MI |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 610473 | 796
H20 | CBMG | CBMG | Lupron |  |  |  | CONTRACT - NO PA REQ'D
H05 | CBMGBED | [NAME] CTR | Lupron |  |  |  | CONTRACT - NO PA REQ'D | 233 [NAME] AVENUE | ATTN: NICOLA BAYNES |  | BROOKLYN | NY | 11205 |  | 7188265913 |  |  |  | 7188265860 |  |  | N |  | CBMG | CBMG |  |  |  | NICOLA BAYNES | 2221001 | N | N | N | N |  | 2 | 01/01/1900
H63 | CBMGBHA | CBMG-BROOKLYN HEIGHTS ANNEX | Lupron |  |  |  | CONTRACT - NO PA REQ'D | 195 MONTAGUE STREET |  |  | BROOKLYN | NY | 11201 |  | 7184228000 |  |  |  |  |  |  | N |  | CBMG | CBMG |  |  | 112937992 |  |  | N | N | Y | Y |  | 6 | 02/25/2010
H18 | CBMGCIC | CBMG-CONEY ISLAND CENTER | Lupron |  |  |  | CONTRACT - NO PA REQ'D | 1230 NEPTUNE AVENUE |  |  | BROOKLYN | NY | 11224 |  | 7186153200 |  |  |  | 7186153335 |  |  | N |  | CBMG | CBMG |  |  |  | PRITIBALIGA | 2201002 | N | N | N | N |  | 1 | 08/16/2001
H15 | CBMGDTC | CBMG-DOWNTOWN CENTER | Lupron |  |  |  | CONTRACT - NO PA REQ'D | 447 ATLANTIC AVENUE |  |  | BROOKLYN | NY | 11217 |  | 7188586300 |  | 7188586300 |  | 7184033591 |  |  | N |  | CBMG | CBMG |  |  |  | MARYANN CARRAO | 2221001 | N | N | N | N |  | 2 | 01/01/1900
H60 | CBMGEC | CBMG-EMPIRE CENTER | Lupron |  |  |  | CONTRACT - NO PA REQ'D | 546 EASTERN PARKWAY |  |  | BROOKLYN | NY | 11225 |  | 7186044800 |  |  |  |  |  |  | N |  | CBMG | CBMG |  |  | 112937992 |  |  | N | N | Y | Y |  | 4 | [NAME]
H17 | CBMGFC | CBMG-FLATBUSH CENTER | Lupron |  |  |  | CONTRACT - NO PA REQ'D | 1000 CHURCH AVENUE |  |  | BROOKLYN | NY | 11218 |  | 7188264064 |  | 8009926227 |  | 7188264075 |  |  | N |  | CBMG | CBMG |  |  |  | [NAME] | 2201002 | N | N | N | N |  | 5 | 08/20/2001
H19 | CBMGKHC | CBMG-KINGS HIGHWAY CENTER | Lupron |  |  |  | CONTRACT - NO PA REQ'D | 3245 NOSTRAND AVENUE |  | ATTN: GYN DEPARTMENT | BROOKLYN | NY | 11229 |  | 7186153777 |  |  |  | 7186153481 |  |  | N |  | CBMG | CBMG |  |  |  | DR.PARK | 2201002 | N | N | N | N |  | 4 | 08/06/2001
H06 | CBMGLC | CBMG-LINDENWOOD CENTER | Lupron |  |  |  | CONTRACT - NO PA REQ'D | 2832 LINDEN BLVD |  |  | BROOKLYN | NY | 11208 |  | 7182402000 |  |  |  | 7182402215 |  |  | N |  | CBMG | CBMG |  |  |  | CATHY BIANCULLI | 2221001 | N | N | N | N |  | 16 | 01/01/1900
CBMG | CBMGPHP | CBMG-PREFERRED HEALTH PARTNERS | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - NO PA REQ'D | 32 COURT ST.    19TH FLOOR | ACCOUNTING, ATTN: IRENE HOFFSTETTER | PREFERRED HEALTH PARTNERS | BROOKLYN | NY | 11201 | 4924 | 7184228111 |  |  |  | 7184228150 |  |  | HCFA |  |  | CBMG |  |  | 112937992 | [NAME], CONTROLLER |  | N | N | N | N |  | 1 | 04/22/2010
CDP | CDPHP | CAPITAL DIST PHYS HEALTH PLAN |  |  |  |  |  | 1223 WASHINGTON AVE |  |  | ALBANY | NY | 12206 |  | 8003455413 |  | 5186413000 |  | 8662437526 |  |  | Adjudicated | 10005318 | APM | CDP | 610415 | 3211506385 | 141745298 | [NAME] ZEBROWSKY | 40294029 | N | N | Y | Y |  | 40 | 12/11/2001
CLA | CLMSPRO | CLAIMSPRO |  |  |  |  |  | 24370 NORTHWESTERN HWY |  |  | SOUTHFIELD | MI | 48075 |  | 8008379600 |  |  |  |  |  |  | Adjudicated |  | PHA |  | 4245 |  | 52-221138 |  |  | N | N | Y | Y |  | 2 | 05/22/2006
CSTWSCLMS | COAST | COASTWISE CLAIMS OFFICE |  |  |  |  |  | 814 MISSION STREET | SUITE 300 |  | SAN FRANCISCO | CA | 94103 |  | 8009557376 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 11/10/2008
COFINITY | COFINITY | COFINITY
COMCO-HMC | COMCO | COMCOTECH-FOR HORIZON MERCY |  |  |  |  |  |  |  |  |  |  |  |  | 8003251810 |  | 8006829094 |  |  |  |  | Adjudicated |  |  |  | 610606 | HMC |  |  |  | N | N | Y | Y |  | 11 | 01/01/1900
CRK | CRK | CAREMARK INC |  |  |  |  |  | [NAME] SERVICE DIV | 6025 SLAUSON AVE |  | CULVER CITY | CA | 90230 |  | 8008246349 |  | 8004212342 |  |  |  |  | Adjudicated |  |  |  | 610029 | CRK |  | KRISTEN |  | N | N | Y | Y |  | 464 | 04/27/2010
ADV | CRKADV | CAREMARK |  |  |  |  |  |  |  |  |  |  |  |  | 8003646331 |  |  |  |  |  |  | Adjudicated |  | APM |  | 4336 | ADV |  |  |  | N | N | Y | Y |  | 80 | [NAME]
APM | CRKAPM | [NAME] |  |  |  |  |  | 750 W JOHN CARPENTER FWAY |  |  | IRVING | TX | 75039 | 5062 | 8003646331 |  |  |  |  |  |  | Adjudicated |  | APM |  | 4336 | HVI | 860217882 |  |  | N | N | Y | Y |  | 201 | 04/27/2010
APM2 | CRKAPM2 | EMPIRE |  | 52 06 | NON-MATCHED CARDHOLDER ID M/I GROUP ID | LOAD MDCOUHC.  BIN 610014 and GROUP UH0712959 | PLEASE NOTIFY [NAME] WHEN YOU RUN THIS PLAN. NEED TO SEE IF WE CAN DISPENSE REFILLS. |  |  |  |  |  |  |  | 8003646331 |  |  |  |  |  | PLEASE NOTIFY [NAME] WHEN YOU RUN THIS PLAN. NEED TO SEE IF WE CAN DISPENSE REFILLS | Adjudicated |  |  |  | 4336 | 44000 |  |  |  | N | N | Y | Y |  | 1 | 03/30/2010
HNET | CRKHNET | HEALTHNET-APM | Lupron | 70 75 | PRODUCT NOT COVERED (WEST, SE), PRIOR AUTH REQUIRED (NE) | FORWARD TO BIOSCRIPT (Northeast) or CURASCRIPT (West, Southwest) | NORTHEAST ID# [NAME] WITH "HN" AND WEST ID# [NAME] WITH "R" |  |  |  |  |  |  |  | 8003646331 |  | 8006417761 |  |  |  | HEALTHNET | Adjudicated |  |  |  | 4336 | HNET |  |  |  | N | N | Y | Y |  | 25 | 04/09/2010
PCS2 | CRKPCS | CAREMARK |  |  |  |  |  |  |  |  |  |  |  |  | 8009665772 |  |  |  |  |  |  | Adjudicated |  |  |  | 610415 | 73227 |  |  |  | N | N | Y | Y |  | 3 | 11/18/2009
 | [NAME] | BCBS OF IOWA | Lupron |  | WILL RECEIVE FULL COST COPAY, INSURANCE PAYS ZERO | FORWARD TO CAREMARK
CAT | [NAME] | CATALYST RX |  |  |  | Click here for BCBS of IOWA |  | [NAME] | SUITE 110 |  | LAS VEGAS | NV | 89147 |  | 8888694600 |  | 8888694240 |  | 7028696206 |  |  | Adjudicated |  |  |  | 5947 | CLAIMCR | 50477048 | KAREN ANKENY |  | N | N | Y | Y |  | 153 | 04/26/2010
C41 | CV1STHL | MAIL HNDLERS-COVENTRY 1ST HLT | Lupron |  |  |  |  | P.O. BOX 8402 |  |  | LONDON | KY | 40742 |  | 8004107778 |  |  |  |  |  | COVENTRY | HCFA |  |  | COVENTRY |  |  |  |  |  | N | N | Y | Y | 25133 | 3 | 01/14/2010
ALTIUS | CVALTIUS | ALTIUS | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - NO PA REQ'D | PO BOX 7147 |  |  | LONDON | KY | 40742 |  | 8003774161 |  | 8008246349 |  |  |  |  | HCFA |  |  | COVENTRY |  | CRK |  |  | 2044001 | N | N | Y | Y | 25133 | 34 | 04/26/2010
C34 | CVCLINK | COVENTRY-CARELINK | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7373 |  |  | LONDON | KY | 40742 |  | 8883482922 | 1 |  |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 550712129 |  | 2044001 | N | N | N | Y | 25133 | 12 | 04/27/2010
C03 | CVDE | COVENTRY OF DELAWARE INC | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7713 |  |  | LONDON | KY | 40742 |  | 8008337423 |  | 8007279951 | 1503 | 3022836785 |  |  | HCFA |  |  | COVENTRY |  |  | 510293139 |  | 2044001 | N | N | N | Y | 25133 | 7 | 04/26/2010
C38 | CVDIAM | COVENTRY OF DELAWARE-DIAMOND PLAN | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7136 |  |  | LONDON | KY | 40742 |  | 8665335154 |  | 8665335154 |  | 3022836785 |  |  | HCFA |  |  | COVENTRY |  |  |  |  |  | N | N | N | Y |  | 2 | 04/02/2010
 | CVFLVIST | COVENTRY-FLORIDA VISTA | Lupron |  |  | ** Need to investigate 2011 benefit details. Submit PA to see if Pharm. [NAME]. can service. Please email [NAME] with result. (Accredo may be the new SPP) ** | CONTRACT - PA REQ'D |  |  |  |  |  |  |  | (866)847-8235 |  |  |  |  |  |  | HCFA
C08 | CVGA | COVENTRY OF GEORGIA INC | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7711 |  |  | LONDON | KY | 40742 |  | 8003952545 |  | 8004702004 |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 510353639 |  | 2044001 | N | N | N | Y | 25133 | 11 | 04/22/2010
C17 | CVGHP | COVENTRY-GROUP HEALTH PLAN | Lupron |  |  | CHECK CONTRACT JOB AID | CONTRACT - NO PA REQ'D | PO BOX 7374 |  |  | LONDON | KY | 40742 |  | 8007553901 |  | 8005464603 |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 510353639 |  | 2044001 | N | N | N | Y | 25133 | 20 | 04/26/2010
C20 | CVHAHBG | HEALTHAMERICA-HBG HMO & POS |  |  | Use if HCP's area code is 717,610 or 570 |  | CONTRACT - PA REQ'D | PO BOX 7089 |  |  | LONDON | KY | 40742 |  | 8007888445 |  | 7175404260 |  | 7175415764 |  |  | HCFA |  |  | COVENTRY |  |  | 541564126 |  | 2044001 | N | N | N | Y | 25133 | 3 | 04/14/2010
C25 | CVHAHBG2 | HEALTHAMERICA-HBG-HLTHASRPPO |  |  | Use if HCP's area code is 717,610 or 570 |  | CONTRACT - PA REQ'D | PO BOX 7089 |  |  | LONDON | KY | 40742 |  | 8007888445 |  | 7175404260 |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 751296086 |  | 2044001 | N | N | N | Y | 25133 | 12 | 04/27/2010
C27 | CVHAPBG | HEALTHAMERICA-PBGH-HLTHASURPPO |  |  | Use if HCP's area code is 412 or 724 |  | CONTRACT - PA REQ'D | PO BOX 7088 |  |  | LONDON | KY | 40742 |  | 8007354404 |  | 7175404260 |  |  |  |  | HCFA | 62137 |  | COVENTRY |  |  | 751296086 |  | 2044001 | N | N | N | Y | 25133 | 14 | 04/27/2010
C21 | CVHAPBG2 | HEALTHAMERICA-PBGH-HMO & POS |  |  | Use if HCP's area code is 412 or 724 |  | CONTRACT - PA REQ'D | PO BOX 7088 |  |  | LONDON | KY | 40742 |  | 8007354404 |  | 7175404260 |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 541564126 | COVENTRY | 2044001 | N | N | N | Y | 25133 | 5 | 04/21/2010
C26 | CVHAPBG3 | HEALTHAMERICA-PBGH-ADVANTRA |  |  |  |  | CONTRACT - PA REQ'D | PO BOX 7087 |  |  | LONDON | KY | 40742 |  | 8002900190 |  | 8003559196 |  |  |  |  | HCFA | 62137 |  | COVENTRY |  |  | 541564126 |  | 2044001 | N | N | N | Y | 25133 | 2 | [NAME]
C19 | CVHCUSA | COVENTRY-HEALTHCARE USA | Lupron |  |  | Forward to Curascript |  | PO BOX 7629 |  |  | LONDON | KY | 40742 |  | 8005666444 |  | 8002956888 |  | 7175415774 |  |  | HCFA | 11003 |  | COVENTRY |  |  | 431702094 |  | 2044001 | N | N | N | Y | 25143 | 8 | 03/29/2010
C45 | CVHLIFOK | COVENTRY HEALTH AND LIFE-OKLAHOMA | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7153 |  |  | LONDON | KY | 40742 |  | 8778378914 |  |  |  |  |  |  | HCFA |  |  | COVENTRY |  |  |  | TAMMY |  | N | N | Y | Y |  | 2 | 04/12/2010
C47 | CVHLIFTN | COVENTRY HEALTH AND LIFE-TENNESSEE | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7170 |  |  | LONDON | KY | 40742 | 7170 | 8667657747 |  |  |  |  |  |  | HCFA |  |  | COVENTRY |  |  |  |  |  | N | N | Y | Y | 25133 | 1 | 03/03/2010
C11 | CVIA | COVENTRY OF IOWA INC | Lupron |  |  |  | CONTRACT - PA REQ'D | P.O. BOX 7709 |  |  | LONDON | KY | 40742 |  | 8002574692 |  |  |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 421244752 |  | 2044001 | N | N | N | Y | 25133 | 3 | 04/22/2010
C12 | CVKS | COVENTRY OF KANSAS INC | Lupron |  |  |  | CONTRACT - PA REQ'D | P.O. 7109 |  | COVENTRY | LONDON | KY | 40742 |  | 8009693343 |  | 8009693343 | 2235 |  |  |  | HCFA |  |  | COVENTRY |  |  | 480840330 |  | 2044001 | N | N | N | Y |  | 16 | 04/27/2010
C16 | CVLA | COVENTRY OF LOUISIANA INC | Lupron |  |  |  | CONTRACT - PA REQ'D | P.O. BOX 7707 |  |  | LONDON | KY | 40742 |  | 8003416613 |  | 8002458327 |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 742381406 |  | 2044001 | N | N | N | Y | 25133 | 6 | 04/27/2010
C18 | CVNE | COVENTRY OF NEBRASKA INC | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7705 |  |  | LONDON | KY | 40742 |  | 8002883343 |  |  |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 421308659 |  | 2044001 | N | N | N | Y | 25133 | 7 | 04/26/2010
C40 | CVNE1STH | COVENTRY NEG 1ST HEALTH | Lupron
 | CVNV | COVENTRY HEALTH AND LIFE-NEVADA | Lupron |  |  | MAJOR MEDICAL SPP = ACCREDO | - NOT A CONTRACT  - INVESTIGATE PBM
C37 | CVOMNI | COVENTRY-OMNICARE | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7150 |  |  | LONDON | KY | 40742 |  | 8663143784 |  | 8668742567 |  |  |  |  | HCFA |  |  | COVENTRY |  |  |  | MICHAELROTHROCK | 2044001 | N | N | N | N | 25150 | 6 | 04/22/2010
C36 | CVPERSC | COVENTRY-PERSONAL CARE | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7141 |  |  | LONDON | KY | 40742 |  | 8005625792 |  |  |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 371241037 |  | 2044001 | N | N | N | Y | 25133 | 9 | 04/26/2010
C22 | CVSHS | COVENTRY-SOUTHERN HLTH SERVS | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7704 |  |  | LONDON | KY | 40742 |  | 8006274872 |  | 8047473700 |  |  |  |  | HCFA |  |  | COVENTRY |  |  | 541576035 |  | 2044001 | N | N | N | Y | 25133 | 25 | 04/23/2010
C29 | [NAME] | COVENTRY-SOUTHERN HLTH SERVS CARENET | Lupron |  |  |  | CONTRACT - PA REQ'D | PO BOX 7702 |  |  | LONDON | KY | 40742 |  | 8002791878 |  | 8006274872 |  |  |  |  | HCFA |  |  | COVENTRY |  |  |  |  | 2044001 | N | N | N | Y | 25142 | 2 | 04/27/2010
C32 | CVWLPTH | COVENTRY-WELLPATH SELECT INC | Lupron |  |  | • FOR GROUP GEHA ONLY, MUST FORWARD TO ACCREDO • FOR GROUP DUKE SELECT, NO PA IS REQD | CONTRACT - PA REQ'D | PO BOX 7102 |  |  | LONDON | KY | 40742 |  | 8008891947 |  | 8007089355 |  | 9194193873 |  |  | HCFA |  |  | COVENTRY |  |  | 561945092 |  | 2044001 | N | N | N | Y | 25133 | 14 | 04/26/2010
CWS | CWS | CALIFORNIA WATER SERVICE |  |  |  |  |  | P.O. BOX 49065 |  |  | SAN JOSE | CA | 95161 |  | 4083678398 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 04/19/2010
CXM | CXM | ANTHEM-COMMUNITY RX |  |  |  | M/I PHARMACY NUMBER FOR ASSISTANCE TO RESOLVE THIS CLAIM REJECT GO TO WWW.EXPRESS-SCRIPTS.COM  ---Forward to Curascript | Non-matched pharmacy OR Pharmacy Not Contracted on DOS  VERIFY ESI ELIGIBILITY . If ESI does not recognize patient - FWD to [NAME] | Forward to Precision RX | 8845 GOVERNOR'S HILL #400 |  | CINCINNATI | OH | 45249 |  | 8006620210 |  | 8003386180 |  |  |  |  | Adjudicated |  |  |  | 610575 | 890000 |  |  |  | N | N | Y | Y |  | 423 | 04/23/2010
CMS-16 | D-AET | AETNA-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8002386279 |  |  |  |  |  |  | Adjudicated |  | AET |  | 610502 | 670000 |  |  |  | N | N | Y | Y |  | 13 | 01/01/1900
CMS-69 | D-ALLIA | ALLIANCE H&L-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8887831780 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 10004 |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
CMS-9 | D-ANT | ANTHEM-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8006620210 |  |  |  |  |  |  | Adjudicated |  | CXM |  | 610575 | CMSDUAL01 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
CMS-15 | D-ANTNX | ANTHEM-MEDICARE PART D-NEXT RX |  |  |  |  |  | 8990 DUKE BLVD |  |  | MASON | OH | 45040 |  | 8006620210 |  | 8668418953 |  |  |  |  | Adjudicated |  |  |  | 610575 | 890000 |  |  |  | N | N | Y | Y |  | 8 | 04/12/2010
CMS-17 | D-BCBS | [NAME] PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8003646331 |  |  |  |  |  |  | Adjudicated |  | APM |  | 4336 | [NAME] |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
CMS-80 | D-BCBSAL | BCBS OF AL  MED- D |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 4915 | RPD
CMS-85 | D-BLCARE | BLUE MEDCARE |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 11552 | ILDR
CMS-46 | D-CDPHP | CDPHP-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8003455413 |  |  |  |  |  |  | Adjudicated |  |  |  | 610415 | PCS |  |  |  | N | N | Y | Y |  | 1 | [NAME]
CMS-86 | D-CIG | CIGNA-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8005589363 |  |  |  |  |  |  | Adjudicated |  | ARGUS-SHP |  | 12353 | 5000000 |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
CIGNATURE | D-CIG2 | CIGNA-MEDICARE PART D |  |  |  |  |  |  |  | MEDICARE PLAN D |  |  |  |  | 8773537660 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 12353 | 3490000 |  | AMY |  | N | N | N | Y |  | 1 | 04/19/2006
CMS-12 | D-CIG2 | CIGNA-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8005589363 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 12353 | 3490000 |  |  |  | N | N | N | Y |  | 8 | 02/20/2006
CMS-98 | D-CIGAZ | CIGNA MEDICARE OF AZ |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 12353 | 3500000
CM-36 | D-CRMK | CAREMARK-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8003646331 |  |  |  |  |  |  | Adjudicated |  |  |  | 12312 | PARTD |  |  |  | N | N | Y | Y |  | 2 | 03/18/2010
CMS-7 | D-CRMK1 | ADVANCE-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8003646331 |  |  |  |  |  |  | Adjudicated |  | APM |  | 4336 | ADV |  |  |  | N | N | Y | Y |  | 25 | 02/21/2006
CMS-75 | D-CRMK2 | MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8003646331 |  |  |  |  |  |  | Adjudicated |  | ADV |  | 14194 | MEDD |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
DELTA HLTH | DELTAH | DELTA HEALTH SYSTEM |  |  |  |  |  | P.O. BOX 80 |  |  | STOCKTON | CA | 95201 | 3080 | 8004178923 |  | 8004185409 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 2 | 12/22/2008
CMS-41 | D-ESI | EXPRESS SCRIPTS-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8008240898 |  |  |  |  |  |  | Adjudicated |  |  |  | 3858 | A4 |  |  |  | N | N | Y | Y |  | 2 | 04/16/2010
CMS-45 | D-ESI | UPMC FOR LIFE-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8775393080 |  |  |  |  |  |  | Adjudicated |  |  |  | 3858 | A4 |  |  |  | N | N | N | Y |  | 2 | 06/22/2007
CMS-74 | D-EXCEL | EXCELLUS BCBS -MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8007245033 |  |  |  |  |  |  | Adjudicated |  |  |  | 610475 |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
CMS-29 | D-GEIS | GEISINGER-MEDICARE PART D | Lupron |  | PAID CLAIM | FORWARD TO CARESITE upon valid reject | WE MAY RECEIVE A PAID CLAIM, BUT WE CAN NO LONGER PROVIDE, CONTRACT TERMINATED |  |  |  |  |  |  |  | 8009884861 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 12353 | 3640000 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
CMS-57 | D-GHI | GHI-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8008240898 |  | 8774446479 |  |  |  |  | Adjudicated |  |  |  | 13344 | 20080229 |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
[NAME] | D-GHP | GATEWAY-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8006855215 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 12353 | 3740000 |  |  |  | N | N | N | Y |  | 2 | 01/01/1900
CMS-35 | D-HIPNY | HIP-MEDICARE PART D |  |  |  |  | CONTRACT - PA REQ'D |  |  |  |  |  |  |  | 8009926227 |  |  |  |  |  |  | Adjudicated |  | HIP |  | 400023 | 20050403 |  |  |  | N | N | N | N |  | 23 | 05/01/2007
CMS-37 | D-HLTSP2 | HEALTHSPRING MED - D |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 12353 | 03580000
CMS-20 | [NAME] | HEALTHSPRINGS-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8009711581 |  | 8003316293 |  |  |  |  | Adjudicated |  | ARG |  | 12353 | 3590000 |  |  |  | N | N | Y | Y |  | 4 | 01/01/1900
CMS-87 | D-HUM | HUMANA-MEDICARE PART D-LI NET | Lupron | 50   70 | NON-MATCHED  PHARMACY  PRODUCT SERVICE NOT COVERED | FORWARD TO RIGHTSOURCE upon valid reject |  |  |  |  |  |  |  |  | 8007831307 |  |  |  |  |  |  | Adjudicated |  |  |  | 610649 | 5440000 |  |  |  | N | N | Y | Y |  | 1 | 04/06/2010
CMS-10 | D-HUM2 | HUMANA-MEDICARE PART D | Lupron | 50   70 | NON-MATCHED  PHARMACY  PRODUCT SERVICE NOT COVERED | FORWARD TO RIGHTSOURCE upon valid reject |  |  |  |  |  |  |  |  | 8008658715 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 610649 | 3200000 |  |  |  | N | N | N | Y |  | 6 | 02/27/2006
CMS-71 | D-MBRHL | MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8666845395 |  | 8663166049 |  |  |  |  | Adjudicated |  |  |  | 610211 | PDP |  |  |  | N | N | Y | Y |  | 22 | 04/22/2010
CMS-6 | D-MDCO | MEDCO-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8009221557 |  | 8004212342 |  |  |  |  | Adjudicated |  | PD |  | 610014 | MEDDPRIME |  |  |  | N | N | Y | Y |  | 39 | 01/01/1900
CMS-72 | D-MDCO | MEDCO-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8009221557 |  |  |  |  |  |  | Adjudicated |  | PD |  | 610014 | MEDDPRIME |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
CMS-18 | D-MDCO1 | YOURX PLAN-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8005902215 |  | 8009221557 |  |  |  |  | Adjudicated |  | PD |  | 610014 | MEDDPRIME |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
CMS-60 | D-MDI | MEDIMPACT MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8009104730 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 50360 |  |  |  | N | N | Y | Y |  | 4 | 01/01/1900
CMS-30 | D-NPS | AHC-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8005465677 |  | 8009286201 |  |  |  |  | Adjudicated |  |  |  | 4758 | DNPS |  |  |  | N | N | Y | Y |  | 1 | 09/04/2008
PSO-MEDCRD | D-PSOLN | [NAME] D |  |  |  |  |  |  |  |  |  |  |  |  | 8778896481 |  | 8007887871 |  |  |  |  | Adjudicated |  | PSS |  | 610097 | 9999 |  |  |  | N | N | Y | Y |  | 33 | 09/05/2007
CMS-84 | D-QUALH | QUALITY HEALTH-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8667472700 |  |  |  |  |  |  | Adjudicated |  |  |  | 11875 | MEDD |  |  |  | N | N | Y | Y |  | 1 | 04/23/2010
CMS-100 | D-REG | REGENCE MEDICARE PART D |  |  |  |  |  | PO BOX 12625 | M/S S4P |  | SALEM | OR | 97309 |  | 8005720316 |  | 8884371508 |  |  |  |  | Adjudicated |  |  |  | 610623 | 2100000 |  | ATTN ; CLAIMS |  | N | N | Y | Y |  | 1 | 02/08/2010
CMS-14 | D-RXA | RX-AMERICA-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8772790372 |  |  |  |  |  |  | Adjudicated |  | RXA |  | 12189 | 5000 |  |  |  | N | N | Y | Y |  | 6 | 02/25/2006
CMS-73 | D-RXAWIN | RX AMERICAN/WINDSOR |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 12189 | PDP
CMS-TO | D-TO | TODAYS OPTION-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8662750015 |  |  |  |  |  |  | Adjudicated |  |  |  | 610211 | MED |  |  |  | N | N | Y | Y |  | 2 | 03/09/2010
TROOP | D-TROOP | TROOP |  |  |  | To determine if Part D eligible, enter Pt ID numb (SSN) and run Test Claim. If Part D eligible, will return correct Pay Plan info. Enter as [NAME], deactivate TROOP, and run Test Claim on plan. |  |  |  |  |  |  |  |  | 8003882316 |  |  |  |  |  |  | Adjudicated |  |  |  | 11727 | 2222222222 |  | NDC |  | N | N | N | N |  | 13 | 01/01/1900
CMS-53 | D-UNI | UNICARE-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8668418953 |  |  |  |  |  |  | Adjudicated |  | PSV |  | 610575 | 9999999999 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
CMS-3 | D-WHI | WALGREENS-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8668006111 |  | 8002072568 |  |  |  |  | Adjudicated |  | WHP |  | 603286 | 1410000 |  |  |  | N | N | N | Y |  | 5 | 02/20/2006
CMS-82 | D-WINSOR | WINSOR-MEDICARE PART D |  |  |  |  |  |  |  |  |  |  |  |  | 8667157519 |  |  |  |  |  |  | Adjudicated |  |  |  | 12189 | MAPD |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
EBC1 | EBC | EMPLOYEE BENEFIT CONCEPTS |  |  |  |  |  | PO BOX 2365 |  |  | FARMINGTON | MI | 48333 |  | 8003558040 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 01/01/1900
[NAME] | EBMSRX | [NAME] |  |  |  |  |  |  |  |  |  | MT |  |  | 8668941504 |  |  |  |  |  |  | Adjudicated |  | TDI |  | 603604 | EBMS |  |  |  | N | N | Y | Y |  | 3 | 04/09/2004
CBA-VT | [NAME] | EBPA INSURANCE |  |  |  |  |  | PO BOX 2365 |  |  | SOUTH BURLINGTON | VT | 5407 |  | 8005258788 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 09/02/2003
EBRX | EBRX | EBRX INC |  |  |  |  |  | 250 E BROAD STREET | SUITE 600 |  | COLUMBUS | OH | 43215 |  | 8008007153 |  |  |  |  |  |  | Adjudicated |  | MDA |  | 610560 | 95 | 251606630 |  |  | N | N | Y | Y |  | 2 | 03/03/2004
EDS | EDS | ELECTRONIC DATA SYSTEMS CORP |  |  |  |  |  | 950 NORTH MERIDIAN STREET | SUITE 1150 |  | INDIANAPOLIS | IN | 46204 | 4288 | 8008428440 |  |  |  |  |  |  | Adjudicated |  |  |  | 610480 | HVI | 75-254822 |  |  | N | N | Y | Y |  | 16 | 01/01/1900
EHIM | EHIM | EMPLOYEE HEALTH INS MGMNT |  |  |  |  |  |  |  |  |  |  |  |  | 2489489900 |  | 2489489900 |  |  |  |  | Adjudicated |  |  |  | 5285 | HVI |  | KELLY |  | N | N | N | N |  | 3 | 03/22/2010
EMP/NEX | EMPNRX | NEXTRX FOR EMPIRE |  |  |  |  |  |  |  |  |  |  |  |  | 8006620210 |  |  |  |  |  |  | Adjudicated |  |  |  | 610575 | EMP01 |  |  |  | N | N | Y | Y |  | 38 | [NAME]
EXP | ESI | EXPRESS SCRIPTS INC |  |  |  | FORWARD TO CURASCRIPT |  | 14000 RIVERPORT DR |  |  | MARYLAND HEIGHTS | MO | 63043 |  | 8008240898 |  | 8004178164 |  | 8003579577 |  |  | Adjudicated |  |  |  | 3858 | A4 |  |  |  | N | N | Y | Y |  | 692 | 11/30/2009
 | ESI | HEALTH CHOICE
 | ESI | PHOENIX HEALTH PLAN
EXCEL | EXCEL | EXCELLUS BCBS HEALTH PLAN INC | Lupron |  |  | FORWARD TO CURASCRIPT OR WALGREENS SPECIALTY ** FOR NEW RX'S ONLY ** | REORDERS SHOULD BE FILLED BY PS. OBTAIN NEW PA IF NECESSARY | 165 COURT STREET |  |  | ROCHESTER | NY | 14647 |  | 8007245033 |  | 5853836532 |  | 8009562397 |  |  | Adjudicated |  | FLRX | EXCEL | 610475 |  |  | ANNERUFLIN, VP FLRX PHARM [NAME] | 5314001 | N | N | Y | Y |  | 75 | 07/22/2008
 | FEPRX | BCBS FEDERAL EMPLOYEE  (FEP) |  |  | FORMERLY PROCESS THRU PCS - BIN# 610029 | IF COPAY IS ABOVE $35 FOR 3.75MG OR $105 FOR 11.25MG, FORWARD TO ACCREDO SPP. | ID# [NAME] WITH "R" GRP# SHOULD BE 65006500 |  |  |  |  |  |  |  | 8003455413 |  |  |  |  |  |  | Adjudicated |  |  |  | 610239 | FEPRX
FMH | FMHBEN | FMH BENEFIT |  |  |  |  |  | PO BOX 25946 |  |  | OVERLAND PARK | KS | 66225 | 5946 | 8009909058 |  | 9136854740 |  | 9133875974 |  |  | HCFA |  |  | COVENTRY | 48117 |  |  |  |  | N | N | N | N |  | 2 | 11/26/2008
FRDM | FRDM | FREEDOM NETWORK |  |  |  |  |  | PO BOX 25938 |  |  | SHAWNEE MISSION | KS | 66225 |  | 8163610666 |  | 8169430277 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 01/01/1900
GHI-RX | GHI | GHI PHARMACY BENEFITS | Lupron |  |  | FORWARD TO BIOSCRIPT |  |  |  |  |  |  |  |  | 8774443614 |  |  |  |  |  | GHI | Adjudicated |  |  |  | 13865 |  |  |  |  | N | N | Y | Y |  | 18 | 01/01/1900
GHS | GHS | GHS DATA MANAGEMENT-BPM |  |  |  |  |  |  |  |  |  |  |  |  | 8884209711 |  |  |  |  |  |  | Adjudicated |  |  |  | 8316 | GHSRX |  |  |  | N | N | N | Y |  | 2 | [NAME]
GILI | GILSBAR | GILSBAR INC |  |  |  |  |  | P.O. BOX 2947 |  |  | COVINGTON | LA | 70434 |  | 8882159841 |  | 5045293505 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 04/19/2010
GPA75 | GPA | GPA
GPP | GPP | GENERAL PRES PROGRAM |  |  |  |  |  | 127 E 59TH STREET |  |  | NEW YORK | NY | 10022 |  | 8003412234 |  |  |  |  |  |  | Adjudicated |  |  |  | 610086 | HVI |  |  |  | N | N | N | N |  | 6 | 04/23/2010
GUARDIAN | GUARD | GUARDIAN |  |  |  |  |  | P.O. BOX 8007 |  |  | APPLETON | WI | 54913 | 8007 | 8008734543 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 05/19/2000
GUNDERSEN | GUNDLHP | GUNDERSEN LUTHERAN HEALTH PLAN |  |  |  |  |  | 1836 SOUTH AVENUE |  |  | LACROSSE | WI | 54601 |  | 6087758007 |  |  |  | 6087758790 |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
HCP1 | HCP1 | HEALTHCARE PARTNERS |  |  |  |  | CONTRACT - PA REQ'D | 19191 S VERMONT ST. | SUITE 200 |  | TORRANCE | CA | 90502 |  | 3103544200 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y | HCP01 | 9 | 04/26/2010
HLL | HILL | HILL PHYSICIANS | Lupron |  |  | MD BUY AND BILL |  | P.O. BOX 8001 |  |  | PARK RIDGE | IL | 60068 | 8001 | 9258208300 |  | 8004455747 |  | 9258203556 |  | HILL PHYSICIANS | HCFA |  |  | HLL |  |  | 942944896 |  | 1906001 | N | N | N | N |  | 5 | 01/06/2010
HIP | HIPNY | HLTH INS PLN OF NY | Lupron |  |  |  | CONTRACT - PA REQ'D | 55 WATER STREET | 12TH [NAME] |  | NEW YORK | NY | 10041 | 8190 | 8009926227 |  | 6464477209 |  |  |  | HIP | Adjudicated |  |  | HIP NY | 400023 | HVI | 131828429 | [NAME], RPH., DIRECTOR INJECTA | 2522005 | N | N | Y | Y |  | 89 | 04/26/2010
H1199 | HIPNY2 | HLTH INS PLN OF NY-1199 | Lupron |  |  |  | CONTRACT - PA REQ'D | 55 WATER STREET | 12TH [NAME] |  | NEW YORK | NY | 10041 | 8190 | 8009926227 |  | 6464477209 |  |  |  | HIP 1199 | Adjudicated |  | HIP | HIP NY | 11800 | HVI |  | [NAME], RPH | 2522005 | N | N | N | N |  | 24 | 01/01/1900
HEALTH 1ST | [NAME] | HEALTH 1ST TPA |  |  |  |  |  | P.O. BOX 672688 |  |  | HOUSTON | TX | 77267 |  | 2818741753 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
HLTHRCOAK | [NAME] | HEALTH REACH-OAKWOOD |  |  |  |  |  |  |  |  |  |  |  |  | 8662571419 |  |  |  |  |  |  | Adjudicated |  |  |  | 9117 | HT |  |  |  | N | N | Y | Y |  | 2 | [NAME]
HTNB | HTNB | HEALTHTRANS-NEW BENEFITS |  |  |  |  |  |  |  |  |  |  |  |  | 8774486182 |  |  |  |  |  |  | Adjudicated |  |  |  | 11677 | HT |  |  |  | N | N | N | N |  | 4 | 01/01/1900
HLTHTRANS | HTRANS | HEALTH TRANS-OAKWOOD |  |  |  |  |  |  |  |  |  |  |  |  | 8778398119 |  |  |  |  |  |  | Adjudicated |  |  |  | 9117 | HT |  |  |  | N | N | Y | Y |  | 4 | 04/12/2010
AGELITY | HTRANS2 | HEALTHTRANS |  |  |  |  |  |  |  |  |  |  |  |  | 8774598475 |  | 8773216755 |  |  |  |  | Adjudicated |  |  |  | 11867 | HT |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
HUDSON | HUDSON | HUDSON HEALTH PLAN |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 5377 | 10000019
ICF | ICF | INDEPENDENT COPAY FOUNDATION (ICF) | Humira and Lupron |  |  | Add to patient profile when referring patient to ICF for copay assistance | Refer to ICF Job Aid and ICF Chart for processing details.
IDEALSCR | IDEALSCR | IDEAL SCRIPTS |  |  |  |  |  |  |  |  |  |  |  |  | 8777472612 |  |  |  |  |  |  | Adjudicated |  |  |  | 11289 |  |  |  |  | N | N | N | N |  | 3 | 12/16/2009
IHA-ECS | IHA | INDEPENDENT HEALTH |  |  | Rejection = Plan limits exceeded: ask them to extend the override for a week instead of just getting a one-day override |  |  | 511 FARBER LAKES DR. |  | ATTENTION :   [NAME] ROGERS | BUFFALO | NY | 14221 |  | 8009939898 |  | 8002471466 | 3621 |  |  |  | Adjudicated | 7002612 |  | IND HLTH | 4626 | HVI | 161080163 |  | 2220001 | N | N | Y | Y |  | 45 | 04/23/2010
IMG -2 | IMG | IMG
IMG-2 | IMG | IMG |  |  |  |  |  | P.O. BOX 88500 |  |  | INDIANAPOLIS | IN | 46208 |  | 8006284664 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 04/26/2010
 | INDBCBSP | INDEPENDENCE BCBS |  |  | * Check prefix tab for PBM and carve-out info |  | If no rx coverage, MD must [NAME] and [NAME]. No SPP to bill medical.
INNV | INNOV | INNOVIANT |  | 50 | NON-MATCHED PHARMACY | FORWARD TO PRESCRIPTION SOLUTIONS |  | 11 SCOTT STREET |  |  | WAUSAU | WI | 54403 |  | 8775592955 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 610127 | 2330000 |  |  |  | N | N | N | Y |  | 15 | 12/15/2008
ARGWAU | INNOV2 | INNOVIANT-WAUSAU |  | 50 | NON-MATCHED PHARMACY | FORWARD TO PRESCRIPTION SOLUTIONS |  |  |  |  |  |  |  |  | 8884593015 |  |  |  |  |  |  | Adjudicated |  | ARG |  | 610127 | 1960000 |  |  |  | N | N | N | Y |  | 5 | 06/25/2004
INSMNGMNT | INSMSVC | INSURANCE MANAGEMENT SERVICES |  |  |  |  |  | PO BOX 15688 |  |  | [NAME] | TX | 79105 |  | 8063736638 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 09/10/2001
KAISERMIDA | KAISER | KAISER PERMANENTE-MID ATLANTIC |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 70000 |  |  |  | N | N | Y | Y |  | 10 | 09/20/2004
[NAME] | KEYBEN | KEY BENEFIT ADMINISTRATORS
KROGER6 | KROGER | KROGER |  |  |  |  |  |  |  |  |  |  |  |  | 8004821285 |  |  |  |  |  |  | Adjudicated |  |  |  | 12882 | KPP |  |  |  | N | N | Y | Y |  | 9 | 10/30/2009
LOCAL 8 | LCL8OH | TOLEDO ELECTRICAL WELFARE |  |  |  |  |  | P.O. BOX 60408 |  |  | ROSSFORD | OH | 43460 |  | 4196664450 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  | SHEREEE |  | N | N | N | N |  | 1 | 01/25/2010
LDI | LDI | LDI PHARMACY BENEFIT MNGMNT |  |  |  |  |  |  |  |  | ST. LOUIS | MO |  |  | 8006529550 |  |  |  |  |  |  | Adjudicated |  |  |  | 800010 | LDI |  |  |  | N | N | Y | Y |  | 6 | 03/15/2010
LIS | LIS | LOW INCOME SUBSIDY | Humira |  |  |  | Medicare Part D Patients only. Refer to Part D LIS Job Aid for processing details.
LMG | LMG | LAKESIDE MED GRP | Lupron |  |  | MD BUY AND BILL |  | ATTN: CLAIMS DEPARTMENT | P.O. BOX 2880 |  | AGOURA HILLS | CA | 91376 |  | 8884727787 |  |  |  | 8186372779 |  | LAKESIDE MEDICAL GROUP | HCFA |  |  | LHC |  |  | 95-415923 | MIGDALIAMOHAMED | 1901001 | N | N | N | N |  | 2 | [NAME]
LMG-GLEN | LMGGLEN | GLENDALE MEMORIAL MED GROUP | Lupron |  |  | MD BUY AND BILL |  | ATTN:  CLAIMS PROCESSING | PO BOX 2880 |  | AGOURA HILLS | CA | 91376 |  | 8186372000 |  |  |  |  |  | LAKESIDE MEDICAL GROUP | HCFA |  |  | LHC |  |  |  | FRANCESCOFEDERICO | 1901001 | N | N | N | N |  | 5 | 04/09/2010
LMG-VERD | LMGVERD | VERDUGO HILLS MEDICAL GROUP | Lupron |  |  | MD BUY AND BILL |  | ATTN: CLAIMS DEPARTMENT | P.O. BOX 1350 |  | AGOURA HILLS | CA | 91376 |  | 8186372000 |  |  |  |  |  |  | HCFA |  |  | LHC |  |  |  |  | 1901001 | N | N | N | N |  | 1 | 03/16/2010
LOOMIS | LOOMIS | LOOMIS BENEFITS
LUMENAN | [NAME] | LUMENOS-ANTHEM |  |  |  |  |  |  |  |  |  |  |  |  | 8002814880 |  |  |  |  |  |  | Adjudicated |  |  |  | 610575 | CDH9999 |  |  |  | N | N | Y | Y |  | 23 | 03/08/2010
LUMRX | LUMRX | WELLPOINT-NEXTRX |  |  |  |  |  |  |  |  |  |  |  |  | 8666303820 |  |  |  |  |  |  | Adjudicated |  |  |  | 610575 | LUMENOS |  |  |  | N | N | N | Y |  | 4 | [NAME]
LUPR167 | LUPR167 | POST LUPRON DRUG STUDY |  |  |  | Add to patient profile when referral indicates patient is part of the post lupron drug study | Two drug study codes available - confirm which plan to load.  [NAME] to Post Lupron Drug Study Job Aid for processing details.
LUPR177 | LUPR177 | POST LUPRON DRUG STUDY |  |  |  | Add to patient profile when referral indicates patient is part of the post lupron drug study | Two drug study codes available - confirm which plan to load.  [NAME] to Post Lupron Drug Study Job Aid for details
MCRX | MAINECR | MAINECARE | Lupron |  |  |  | UNABLE TO PROVIDE |  |  |  |  |  |  |  | 8004524694 |  |  |  |  |  |  | Adjudicated |  |  |  | 5526 | MEPOP |  |  |  | N | N | N | Y |  | 4 | 01/01/1900
MAXCARE | MAXCAR | PHARMACY PROVIDERS OF OK-MAXCA |  |  |  |  |  |  |  |  |  |  |  |  | 8002597765 |  |  |  |  |  |  | Adjudicated |  |  |  | 610170 | MRX |  |  |  | N | N | Y | Y |  | 3 | 02/11/2010
MXR1 | MAXOR | MAXOR |  |  |  |  |  | 2355 WAUKEGAN RD. |  |  | DEERFIELD | IL |  |  | 8006870707 |  |  |  |  |  |  | Adjudicated |  | MXR |  | 5377 | 10000019 |  |  |  | N | N | Y | Y |  | 2 | 03/31/2005
MEDCOSTNC1 | MCOST | MEDCOST BENEFIT SERVICES |  |  |  |  |  | P.O. BOX 25987 |  |  | WINSTON SALEM | NC | 27114 |  | 8007951023 |  | 8773665110 |  |  |  |  | HCFA |  |  |  |  |  |  | ATTN ;CLAIMS |  | N | N | N | N |  | 2 | 05/14/2007
KMH-AZ | MDCOAMC | AMERICHOICE-AZ PHYSICIANS IPA |  |  |  |  |  |  |  |  |  |  |  |  | 8009221557 |  |  |  | 8668439241 |  |  | Adjudicated | HM18INSN | PD | KMH | 610014 | VCD |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
MVP2 | MDCOMVP | MVP |  |  |  |  | CONTRACT - NO PA REQ'D | 625 STATE STREET |  |  |  |  |  |  | 8886876277 |  | 8005680458 |  |  |  |  | Adjudicated |  | PD | MVP | 610014 | TPB |  |  |  | N | N | Y | Y |  | 75 | 01/01/1900
PD | MDCOPD | PAID PRESCRIPTIONS-MEDCO HLTH |  |  |  |  |  | 100 SUMMIT AVE |  |  | MONTVALE | NJ | 7645 |  | 8009221557 |  |  |  |  |  |  | Adjudicated |  |  |  | 610014 | VCD | 223461737 |  |  | N | N | Y | Y |  | 1960 | 04/27/2010
UHC-FL | MDCOUHC | UNITED HEALTHCARE-FLORIDA | Lupron |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  | [NAME] |  |  |  |  |  |  | 8003106826 |  | 8009221557 |  |  |  |  | Adjudicated |  | PD | KMH | 610014 | VCD |  |  |  | N | N | Y | Y |  | 2 | 07/06/2007
UHC-NY | MDCOUHC | UNITED HEALTHCARE-NEW YORK | Lupron |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  |  |  | [NAME] |  |  |  |  | 8003106826 |  | 8009221557 |  |  |  |  | Adjudicated |  |  | KMH | 610014 | VCD |  |  |  | N | N | N | Y |  | 9 | 04/27/2010
UHC-WI | MDCOUHC | UNITED HEALTHCARE-WISCONSIN | Lupron |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  |  |  | [NAME] |  |  |  |  | 8003106826 |  | 8009221557 |  |  |  |  | Adjudicated |  | PD | KMH | 610014 | VCD |  |  |  | N | N | N | N |  | 1 | 01/15/2007
PSO1 | MDI | MEDIMPACT |  |  |  |  |  | 10660 SCRIPPS BLVD | STE 100 |  | SAN DIEGO | CA | 92131 |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  |  |  | 3585 | 26110 |  |  |  | N | N | Y | Y |  | 5 | [NAME]
MED/CC | [NAME] | 1ST CAROLINA CARE |  |  |  |  | 0 | 42 MEMORIAL DRIVE | SUITE 1 |  | PINEHURST | NC | 28374 |  | 8007882949 |  | 8005748556 |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 34400 |  |  |  | N | N | N | Y |  | 1 | 02/16/2006
MED-FIRST | MDI1CH | MEDIMPACT FIRST CHOICE |  |  |  |  |  |  |  |  | DEERFIELD | IL | 60015 |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  |  |  | 3585 | 49530 |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
MDI | MDI2 | MEDIMPACT |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 56020
MEDHAP3 | [NAME] | MED-IMPACT ALLICANCE HEALTH |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 10004
MDI-AZ | MDIAZ | MEDIMPACT HEALTHNET AZ PPO |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 40020
MDI-BCBS | MDIBCBS | MEDIMPACT |  |  |  |  |  |  |  |  |  |  |  |  | 8002391023 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 23615 |  |  |  | N | N | Y | Y |  | 52 | 01/01/1900
MDI-BSWNY | MDIBCBS2 | MEDIMPACT-BCBS OF WESTERN NY |  |  |  |  | PBM changed to Medco. |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 58150 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
BMI2 | MDIBCBS3 | BCBS OF MICHIGAN (MEDIMPACT) |  | 52    R6 | NON-MATCHED CARDHOLDER ID →   PRODUCT/SERVICE → NOT APPROPRIATE FOR THIS LOCATION | Research [NAME] or [NAME] TO WALGREENS-ANN ARBOR | Need to forward to Walgreens - Ann Arbor if patient lives in Michigan only. Any other state, must call Rx plan to determine where to fill. | 8007882949 |  |  |  | Adjudicated | 3585 | 99500 | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 99500
[NAME] | MDIBERW | MEDIMPACT-BERWIND BENEFITS |  |  |  |  |  |  |  |  |  |  |  |  | 8002391023 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 70712 |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
MDI BLUE | MDIBLCR | MEDIMPACT-BLUE CARE NETWORK |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 23221 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
MDI-BLUECA | MDIBLCR | MEDIMPACT-BLUE CARE NETWORK |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 23221 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
MDI-CAPP | MDICAP | MEDIMPACT |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  | 8585662727 |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 10180 |  |  |  | N | N | N | Y |  | 1 | 11/21/2002
MED-CHS | MDICHS | MEDIMPACT-CAROLINA HEALTHCARE |  |  |  |  |  |  |  |  |  |  |  |  | 8887831770 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 34106 |  |  |  | N | N | Y | Y |  | 6 | 01/01/1900
MDI-CIGNA | MDICIG | MEDIMPACT |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated | 1326042870 | MDI |  | 3585 | 30300 |  |  |  | N | N | Y | Y |  | 2 | 01/01/1900
MDI/CARE | [NAME] | MEDIMPACT-MEDCARE |  |  |  |  |  |  |  |  |  |  |  |  | 8007291174 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 38820 |  |  |  | N | N | N | Y |  | 2 | 01/06/2010
MEDIMP-EMP | MDIEMP | MEDIMPACT-EMPIRE |  |  |  |  |  | 10660 SCRIPPS BLVD | STE 100 |  | SAN DIEGO | CA | 92131 |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 33000 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
[NAME] | MDIGHO | MED IMPACT GROUP HEALTH OPTION |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 38850 |  |  |  | N | N | N | Y |  | 3 | 04/09/2008
MDI-GHO1 | MDIGHO | MEDIMPACT GROUP HEALTH OPTIONS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 38810
MDIHAP | MDIHAP | MEDIMPACT-HAP |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 10002 |  |  |  | N | N | N | Y |  | 4 | 03/09/2004
MDIHAP2 | MDIHAP | MEDIMPACT-HAP |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  |  | MDI | 3585 | 10002 |  |  |  | N | N | Y | Y |  | 2 | 04/21/2010
[NAME] | [NAME] | MED IMPACT |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  |  |  | 27003 | 40020 |  |  |  | N | N | Y | Y |  | 5 | 03/16/2010
MDIHAP4 | MDIHAP4 | MEDIMPACT-HAP |  |  |  |  |  | 10660 SCRIPPS BLVD | STE 100 |  | SAN DIEGO | CA | 92131 |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 14100 |  |  |  | N | N | N | Y |  | 7 | 01/01/1900
MDI-AZ2 | MDIHNAZ | MEDIMPACT-HEALTHNET OF AZ |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 40020 |  |  |  | N | N | N | Y |  | 2 | 09/10/2001
MDI-HLTHPL | MDIHPI | MEDIMPACT FOR HEALTH PLANS INC |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 35026
MEDHAR | [NAME] | MEDIMPACT-HARVARD PILGRIM | Lupron |  |  | FORWARD TO CURASCRIPT | KEEP AT PS IF WE RECEIVE A COPAY |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 35000 |  |  |  | N | N | Y | Y |  | 27 | 02/26/2004
MDI/HARPIL | [NAME] | MEDIMPACT-HARVARD PILGRIM |  |  |  |  |  | 2355 WAUKEGAN RD |  |  | DEERFIELD | IL | 60015 |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 35005 |  |  |  | N | N | N | Y |  | 1 | 05/07/2003
MDI-HLTPLS | MDIHPLS | HEALTH PLUS |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  |  |  | 3585 | 23180 |  |  |  | N | N | Y | Y |  | 3 | 01/01/1900
MDI-HLTH+ | [NAME] | MEDIMPACT-HEALTH PLUS OF MI |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 23050 |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
HEALTHPAR | MDIHPT | MED-IMPACT HEALTH PARTNERS |  |  |  |  |  |  |  |  |  |  |  |  | 8004927259 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 24002 |  |  |  | N | N | N | Y |  | 12 | 09/03/2008
MDIJPFARLY | MDIJPF | MEDIMPACT-JP FARLEY |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 36440 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
MDI-KPS | [NAME] | MEDIMPACT KPS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 491000
[NAME] | MDIKPS2 | MEDIMPACT KPS HEALTH PLAN |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 49446
MDIMED1 | MDIMDCA | MEDIMPACT FOR MEDICA |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 99500 |  |  |  | N | N | Y | Y |  | 8 | 12/04/2003
MDI-MEDNTW | MDIMEDN | MEDICAL NETWORK-MED IMPACT |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 65455 |  |  |  | N | N | Y | Y |  | 1 | 02/26/2008
MDI-NET | MDINET | MEDIMPACT FOR NETWORK |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 35017 |  |  |  | N | N | N | Y |  | 2 | 01/01/1900
MD-NHEALTH | MDINETH | NHEALTH INC |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 36065 |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
MED/NORTHW | MDINWA | MEDIMPACT NORTHWEST ADMINISTRATION |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 38151
MEDOCH | MDIOCH | MEDIMPACT |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 38600 |  |  |  | N | N | Y | Y |  | 15 | 01/01/1900
MDI-SJ | MDISANJ | MEDIMPACT-SAN JOAQUIN |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 56300 |  |  |  | N | N | N | Y |  | 1 | 08/22/2007
MDI-SLOAN | [NAME] | SLOAN LAKE-MED IMPACT |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 46400 |  |  |  | N | N | N | Y |  | 1 | 11/02/2004
MDI-SHEET | MDISMW | MEDIMPACT-SHEET METAL WORKERS |  |  |  |  |  |  |  |  |  |  |  |  | 8882721401 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 31900 |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
MDI-STAZ | MDISTAZ | MEDIMPACT FOR STATE OF AZ |  |  |  |  |  |  |  |  |  |  |  |  | 8886486769 |  |  |  |  |  |  | Adjudicated |  |  |  | 3585 | 28914 |  |  |  | N | N | Y | Y |  | 2 | 01/01/1900
STCMDI | MDISTC | MEDIMPACT SELECT HEALTH |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 27003
SUNRX-MDI | MDISUN | SUN RX-MEDIMPACT |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  | 8007861791 |  |  |  |  | Adjudicated |  |  |  | 3585 | 31185 |  |  |  | N | N | N | Y |  | 1 | 01/28/2010
MDI-UMR | MDIUMR | MED IMPACT-UMR |  |  |  |  |  |  |  |  |  |  |  |  | 8007882949 |  |  |  |  |  |  | Adjudicated |  | MDI |  | 3585 | 66666 |  |  |  | N | N | Y | Y |  | 4 | 01/01/1900
MDI-WHP | MDIWELL | MED-IMPACT WELBORN HEALTH PLAN |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 15200
 | MEDEAMER | MEDEAMERICA |  | 70 | PRODUCT SERVICE NOT COVERED | FORWARD TO BIOSCRIP
MEDMUTUAL | MEDMUT | MEDICAL MUTUAL |  |  |  |  |  | P.O. BOX 6018 |  |  | CLEVELAND | OH | 44101 | 6018 | 8003621279 |  | 8002582873 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 04/23/2010
MEDSCRIPT | MEDSCRPT | MEDSCRIPT |  |  |  |  |  |  |  |  |  |  |  |  | 8009105992 |  |  |  |  |  |  | Adjudicated |  |  |  | 610705 | MEDSCRIPT |  |  |  | N | N | N | Y |  | 4 | 02/08/2010
MEM | MEM | [NAME] | Lupron |  |  | For Memorial IPA, the authorization for a quantity of 1 = 1 inj. regardless of dose. For other health plans, quantity does not always correlate to number of injections (e.g. qty of 3 may = 1 - 22.5mg dose.) | CONTRACT - PA REQ'D. |  |  |  | LONG BEACH | CA | 90809 |  | 5629819500 |  | 5629819500 | 2130 | 5629819521 |  | [NAME] | HCFA |  |  | [NAME] |  |  | 954688643 | CATHYGEIS | 1900001 | N | N | N | N |  | 8 | 04/23/2010
MEM-ANAHM | MEMHCA | [NAME] | Lupron |  |  | For Memorial IPA, the authorization for a quantity of 1 = 1 inj. regardless of dose. For other health plans, quantity does not always correlate to number of injections (e.g. qty of 3 may = 1 - 22.5mg dose.) | CONTRACT - PA REQ'D. | 2525 CHERRY AVE #250 |  |  | LONG BEACH | CA | 90806 |  | 5629819500 |  | 5629819500 | 130 | 5629819521 |  |  | HCFA |  |  | [NAME] |  |  | 954688643 | BRANDANRECHSTEINER | 1900001 | N | N | N | N |  | 1 | 01/08/2010
MEM-ORANGE | MEMHCO | [NAME] | Lupron |  |  | For Memorial IPA, the authorization for a quantity of 1 = 1 inj. regardless of dose. For other health plans, quantity does not always correlate to number of injections (e.g. qty of 3 may = 1 - 22.5mg dose.) | CONTRACT - PA REQ'D. | 2525 CHERRY AVE #250 |  |  | LONG BEACH | CA | 90806 |  | 5629819500 |  | 5629819500 | 130 | 5629819521 |  |  | HCFA |  | MEM | [NAME] |  |  | 954688643 | BRANDANRECHSTEINER | 1900001 | N | N | N | N |  | 2 | 04/25/2005
MIDCHOICE | MIDCHOI | MIDLANDS CHOICE |  |  |  |  |  | PO BOX 5809 |  |  | TROY | MI | 48007 |  | 8006058259 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 10/29/2007
MISSIPPI | MISSHP | MISSIPPI HEALTH PARTNERS |  |  |  |  |  | P.O. BOX 23908 |  |  | [NAME] | MS | 39225 |  | 8002381344 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
MMSI | MMSI | MMSI |  |  |  |  |  | 4001 41ST NORTHWEST |  |  | ROCHESTER | MN | 55901 |  | 8006356671 |  | 8006456296 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 01/01/1900
MEDTRAK | [NAME] | MEDTRAK SERVICES |  |  | Hover mouse here for comments |  |  | 6400 GLENWOOD | STE 104 | MEDTRAK SERVICES | OVERLAND PARK | KS | 66202 |  | 8007714648 |  | 9132622187 |  | 9132628939 |  |  | Adjudicated |  |  |  | 800004 | 8126 |  |  |  | N | N | Y | Y |  | 7 | 04/22/2010
MUTASSUR | [NAME] | MUTUAL ASSURANCE |  |  |  |  |  | PO BOX 42096 |  |  | OKLAHOMA CITY | OK | 73123 | 3096 | 8008253540 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 09/08/2004
NAVITUS | NAV | NAVITUS HEALTH SOLUTIONS |  |  |  |  |  |  |  |  |  |  |  |  | 8663332757 |  |  |  |  |  |  | Adjudicated |  |  |  | 610602 | BLN |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
NEVITUS | NAVETF | NAVITUS |  |  |  |  |  | 5 INNOVATION COURT | SUITE 5 |  | APPLETON | WI | 54914 |  | 8663332757 |  | 9202257010 |  | 9202257002 |  |  | Adjudicated |  | NEVITUS |  | 610602 | ETF |  |  |  | N | N | Y | Y |  | 2 | 04/15/2010
HIRSP | NAVHIR | HIRST |  |  |  |  |  |  |  |  |  |  |  |  | 8002703877 |  |  |  |  |  |  | Adjudicated |  | NEVITUS |  | 610602 | NVT |  |  |  | N | N | Y | Y |  | 1 | 11/14/2005
NAVITUS-OC | NAVOCM | NAVITUS HEALTH SOLUTIONS-OCM |  |  |  |  |  |  |  |  |  |  |  |  | 8663332757 |  |  |  |  |  |  | Adjudicated |  |  |  | 610602 | NVT |  |  |  | N | N | Y | Y |  | 4 | 04/12/2010
NEXTRX | NEXTRX | NEXTRX |  |  |  |  |  |  |  |  |  |  |  |  | 8666303820 |  |  |  |  |  |  | Adjudicated |  |  |  | 610053 | 7700630 |  |  |  | N | N | Y | Y |  | 1 | 09/08/2009
NGS | NGS | NGS AMERICA INC |  |  |  |  |  | PO BOX 7676 |  |  | ST. CLAIR SHORES | MI | 48080 |  | 8005211555 |  | 8107797676 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 2 | 11/02/2005
NGS-5810 | NGSAM | NGS AMERICAN |  |  |  |  |  | P.O. BOX 5810 |  |  | TROY | MI | 48007 |  | 8005211555 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
NMH | NMH | NATIONAL MED HLTH CARD |  |  |  |  |  | 2355 WAUKEGAN RD. |  |  | DEERFIELD | IL |  |  | 8006453332 |  | 8003927826 |  |  |  |  | Adjudicated |  |  |  | 3650 | 64 |  |  |  | N | Y | N | Y |  | 8 | [NAME]
[NAME] | NMH | NATIONAL MED HLTH CARD |  |  |  |  |  |  |  |  |  |  |  |  | 8008801188 |  | 6305773100 |  |  |  |  | Adjudicated |  | NMH |  | 3650 | 64 |  |  |  | N | Y | Y | Y |  | 6 | 11/04/2008
NMH3 | [NAME] | NATIONAL MED HEALTH CARD |  |  |  |  |  |  |  |  |  |  |  |  | 8006453332 |  |  |  |  |  |  | Adjudicated |  | NMH |  | 610011 | NMHC |  |  |  | N | N | N | Y |  | 2 | 01/01/1900
NPS | NPS | NATIONAL PRESCRIPTION SERVICE |  |  |  |  |  |  |  |  |  |  |  |  | 8005465677 |  |  |  |  |  |  | Adjudicated |  |  |  | 4758 | NPS |  |  |  | N | N | Y | Y |  | 14 | 04/15/2010
ONENET | ONENET | ONENET PPO |  |  |  |  |  | P.O. BOX 934 |  |  | FREDERICK | MD | 21705 | 934 | 8008495370 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
PAI | PAI | PHARMACY ASSOCIATES |  |  |  |  |  | PO BOX 23007 |  |  | LITTLE ROCK | AR | 72221 | 3007 | 8008801188 |  | 5012212330 |  |  |  |  | Adjudicated |  | NMH |  | 601577 | 38 |  |  |  | N | Y | N | Y |  | 5 | 02/18/2004
PAP | PAP | [NAME] | Humira and Lupron |  |  | Add to patient profile when referring patients to PAP for assistance | For uninsured and underinsured patients. Refer to the PAP Job Aid for processing details. |  |  |  |  |  |  |  | (800) 222-6885
PCN | PCN | PHARMACEUTICAL CARE NETWORK |  |  |  |  |  | 2355 WAUKEGAN RD. |  |  | DEERFIELD | IL |  |  | 8007770074 |  |  |  |  |  |  | Adjudicated |  | NMH |  | 610011 | IRX |  |  |  | N | Y | Y | Y |  | 5 | 06/27/2006
PCS | PCS | PCS |  |  |  |  |  |  |  |  | SCOTTSDALE | AZ | 85260 | 6719 | 8003455413 |  |  |  |  |  |  | Adjudicated | 24960 | APM |  | 610415 | PCS |  |  |  | N | N | Y | Y |  | 408 | 07/09/2009
 | PCS | PRINCIPAL FINANCIAL GROUP |  | 75 | PRIOR AUTHORIZATION REQUIRED | FORWARD TO CAREMARK
PDM3 | PDM | PHARMACY DATA MANAGEMENT |  |  |  |  |  |  |  |  |  |  |  |  | 8007674226 |  |  |  |  |  |  | Adjudicated |  |  |  | 610020 | PBD09 |  |  |  | N | N | Y | Y |  | 1 | 02/23/2010
MED-BEN | PDM2 | HEALTHREACH RX (MED BEN-PDM) |  |  |  |  |  |  |  |  |  |  |  |  | 8006868425 |  | 8007674226 |  |  |  |  | Adjudicated |  | PDM |  | 610020 | 99990282 |  |  |  | N | N | Y | Y |  | 3 | 08/16/2005
PDM | PDM3 | PHARMACY DATA MGMT |  |  |  |  |  | HEALTHSTAR | 124 S MAIN ST |  | POLAND | OH | 44514 | 300 | 8007674226 |  | 8476733113 |  |  |  |  | Adjudicated |  |  |  | 610020 | MEDDPDM |  |  |  | N | N | Y | Y |  | 3 | 03/19/2010
PEKIN1587 | PEKINLI | PEKIN LIFE INSURANCE CO |  |  |  |  |  | P.O. BOX 1587 |  |  | PEKIN | IL | 61555 | 1587 | 8004470122 |  | 8003719622 | 2782 |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 04/12/2006
PERFORMRX | PERFRX | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 600428 | 02920000
PHA | PHA | [NAME] |  |  |  |  |  | 25 BLACKSTONE VALLEY PL |  |  | LINCOLN | RI |  | 2865 | 8007771023 |  |  |  |  |  |  | Adjudicated |  |  |  | 610468 | PC2 |  |  |  | N | N | Y | Y |  | 20 | 04/21/2010
PHA-HP | PHA | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  | 8007771023 |  |  |  |  |  |  | Adjudicated |  | PHA |  | 610468 | PC2 |  |  |  | N | N | Y | Y |  | 2 | 07/21/2004
PHA-FALL | PHAFALL | PHARMACARE-FALLON COMM HP |  |  |  |  |  |  |  |  |  |  |  |  | 8007771023 |  |  |  |  |  |  | Adjudicated |  | PHA |  | 610468 | FCHP |  |  |  | N | N | N | Y |  | 3 | 01/01/1900
PHA-LOCKH | PHALM | PHARMACARE-LOCKHEED MARTIN |  |  |  |  |  |  |  |  |  |  |  |  | 8885623784 |  |  |  |  |  |  | Adjudicated |  |  |  | 610468 | PHM |  |  |  | N | N | N | Y |  | 1 | 12/14/2009
PIERCE | PIERCE | PIERCE ADMINISTRATION |  |  |  |  |  | PO BOX 2271 |  |  | FLORENCE | SC | 29503 |  | 8887221668 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 06/19/2009
P&S 60 | PLUSTM60 | PLUMBERS-STEAMFITTERS LOCAL 60 |  |  |  |  |  | P.O. BOX 845 |  |  | BUCKEYSTOWN | MD | 21717 |  | 5048853062 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
PMP | PMEDP | PROVIDER MED PHMCY |  |  |  |  |  | 2448 E 81ST ST | SUITE 5010 |  | TULSA | OK | 7 | 4137 | 8003646440 | 2 | 9184888478 |  |  |  |  | Adjudicated |  | NMH |  | 610619 | PMP |  |  |  | N | Y | Y | Y |  | 1 | 02/17/2004
PMK | PMK | SCRIPT SOLUTIONS (PRO-MARK) |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 900020 | CLAIMNE
PREM | PREM | PREMIER PHARMACY |  |  |  |  |  |  |  |  |  |  |  |  | 8002474526 |  |  |  |  |  |  | Adjudicated |  |  |  | 600518 | A |  |  |  | N | N | N | N |  | 3 | 01/06/2009
PFC | PRFCARE | PREFERRED CARE INC |  |  |  | CHECK CONTRACT JOB AID | CONTRACT - NO PA REQ'D | P.O. BOX 22920 |  |  | ROCHESTER | NY | 14692 | 2920 | 8009993920 |  |  |  | 5852588621 |  |  | HCFA | 110441GK |  | PREFERRED |  |  | 161098173 | CARLREED, RPH, MBA |  | N | N | N | Y |  | 8 | 04/21/2010
PGO | PRIMEGO | GOLDNET | Lupron | 70 | PRODUCT SERVICE NOT COVERED | FORWARD TO TRIESSENT | US BANK (ONLY) (FBO PREXFIX)  Verify Major Medical | PO BOX 64812 |  |  | ST PAUL | MN | 55164 | 812 | 8008214795 |  |  |  |  |  | BCBS MN | Adjudicated |  |  |  | 610455 | PGIGN |  |  |  | N | N | N | Y |  | 33 | 04/19/2010
PRIMEIL | PRIMEIL | [NAME] |  |  |  |  |  | MAIL ROUTE BCBSIL | PO BOX 14624 |  | LEXINGTON | KY | 40512 |  | 8008214795 |  |  |  |  |  |  | Adjudicated |  | PRIMTHER |  | 11552 | ILSC |  |  |  | N | N | Y | Y |  | 17 | 11/06/2007
PRIMEILHMO | [NAME] | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  | 8008214795 |  |  |  |  |  |  | Adjudicated |  | PRIMTHER |  | 11552 | ILDR |  |  |  | N | N | Y | Y |  | 12 | 03/15/2010
PRIMENM | PRIMENM | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  | 8008214795 |  |  |  |  |  |  | Adjudicated |  | PRIMTHER |  | 11552 | NMDR |  |  |  | N | N | N | Y |  | 1 | 01/01/1900
PRIMEOK | PRIMEOK | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  | 8008214795 |  |  |  |  |  |  | Adjudicated |  |  |  | 11552 | 1217 |  |  |  | N | N | Y | Y |  | 6 | 04/22/2010
PRIME-OK | PRIMEOK2 | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  | 8008214795 |  |  |  |  |  |  | Adjudicated |  |  |  | 11552 | 1215 |  |  |  | N | N | Y | Y |  | 1 | 04/21/2010
PRIMETH | PRIMETH | PRIME THERAPEUTICS |  |  |  |  |  |  |  |  |  |  |  |  | 8008214795 |  |  |  |  |  |  | Adjudicated |  |  |  | 12833 | FLBC |  |  |  | N | N | Y | Y |  | 64 | 04/15/2010
PRIMTHER | PRIMETH2 | PRIME THERAPEUTICS |  |  |  |  |  | 2355 WAUKEGAN RD |  |  | DEERFIELD | IL | 60015 |  | 8008214795 |  |  |  |  |  |  | Adjudicated |  |  |  | 610455 | RXNEB |  |  |  | N | N | N | Y |  | 11 | 04/27/2010
PRIMETX | PRIMETX | [NAME] |  |  |  |  |  | P.O. BOX 64812 |  |  | ST PAUL | MN | 55164 | 812 | 8008214795 |  |  |  |  |  |  | Adjudicated |  | PRIMTHER |  | 11552 | BCTX |  |  |  | N | N | Y | Y |  | 16 | 04/23/2010
PROCAR | PROCARE | PROCARE |  |  |  |  |  | 3090 PREIMIER PARKWAY |  |  | DELUTH | GA | 30096 |  | 8006993542 |  |  |  |  |  |  | Adjudicated |  |  |  | 9430 |  |  | COURTNEY |  | N | N | N | Y |  | 3 | 10/13/2008
PROCARE | PROCARE2 | PROCARE |  |  |  |  |  |  |  |  |  |  |  |  | 8006993542 |  |  |  |  |  |  | Adjudicated |  |  |  | 13501 |  |  |  |  | N | N | Y | Y |  | 4 | 02/27/2009
PROCARE3 | PROCARE3 | PROCARE-AVMED |  | 75 | PRIOR AUTHORIZATION REQUIRED | FORWARD TO CURASCRIPT |  |  |  |  |  |  |  |  | 8002371255 |  |  |  |  |  |  | Adjudicated |  |  |  | 12163 | MEDD? |  |  |  | N | N | Y | Y |  | 17 | 09/19/2008
PSV | PROSRV | PROSERVE-WELLPOINT |  |  |  | M/I PHARMACY NUMBER FOR ASSISTANCE TO RESOLVE THIS CLAIM REJECT GO TO WWW.EXPRESS-SCRIPTS.COM  ---Forward to Curascript | Non-matched pharmacy OR Pharmacy Not Contracted on DOS  VERIFY ESI ELIGIBILITY . If ESI does not recognize patient - FWD to [NAME] | PO BOX 9082 |  |  | OXNARD | CA | 93031 | 9082 | 8006783784 |  | 8009627378 |  |  |  |  | Adjudicated |  |  |  | 610053 | 7Q 7700630 |  |  |  | N | N | N | Y |  | 121 | 04/26/2010
KMH-AZ-PSS | PSO | AMERICHOICE-AZ PHYSICIANS IPA (APIPA) |  | 50 | NON-MATCHED PHARMACY NUMBER | FORWARD TO PREFERRED HOME CARE | ** SET ACTIVITY FOR KRISTI HARTWIG TO CALL HCP ** |  |  |  |  |  |  |  | 8007887871 |  |  |  |  |  |  | Adjudicated |  | PSS |  | 610494 | 9999 |  |  |  | N | N | Y | Y |  | 24 | 01/01/1900
KMH-PAPD | PSO | AMERICHOICE-PA |  |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  | 8045 LEESBURG PIKE |  |  | VIENNA | VA | 22182 |  | 8007887871 |  |  |  | 9732975630 |  |  | Adjudicated | HM18INSN | PSS | KMH | 610494 | 9999 |  | DOUGLASROSE, VP, PHARMACY |  | N | N | Y | Y |  | 2 | 01/01/1900
POS | PSO | [NAME] SOLUTIONS |  |  |  |  |  |  |  |  |  |  |  |  | (866) 218-5445 (888) 739-5820 (MD line to call in script for UHC members only) |  |  |  | 8008533844 |  |  | Adjudicated |  | PSS |  | 610494 | 9999 |  | PACIFICARE OF CA |  | N | N | Y | Y |  | 6 | 02/24/2005
PSO | PSO | [NAME] SOLUTIONS |  |  |  |  |  | PACIFICARE PHARMACY CTRS |  |  | DEERFIELD | IL |  |  | 8007887871 |  |  |  |  |  |  | Adjudicated |  | PSS |  | 610494 | 9999 |  |  |  | N | Y | Y | Y |  | 48 | 10/28/2004
KMH-NJ | PSO | [NAME] SOLUTIONS (AMERICHOICE-NJ) |  | 75 | PRIOR AUTHORIZATION REQUIRED | FORWARD TO PRESCRIPTION SOLUTIONS |  | 8045 LEESBURG PIKE |  |  | VIENNA | VA | 22182 |  | 8007887871 |  | 8007114555 |  | 9732975630 |  |  | Adjudicated | HM18INSN | PSS | KMH | 610494 | 9999 |  | DOUGLASROSE, VP, PHARMACY | 2295001 | N | N | Y | Y |  | 14 | 01/01/1900
RXSOL | PSO1 | [NAME] SOLUTIONS |  |  |  |  |  |  |  |  |  |  |  |  | 8007887871 |  |  |  |  |  |  | Adjudicated |  |  |  | 610613 | 2417 |  | CHRIS |  | N | N | Y | Y |  | 1 | 01/01/1900
UHC-FL-PSS | PSOUHC | UNITED HEALTHCARE-FLORIDA | Lupron |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  |  |  |  |  |  |  |  | 8008660931 |  |  |  |  |  |  | Adjudicated |  | PSS |  | 610494 | 9999 |  |  |  | N | N | Y | Y |  | 15 | 11/02/2009
UHC-MD-PSS | PSOUHC | UNITED HEALTHCARE-MARYLAND | Lupron |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  |  |  |  |  |  |  |  | 8008660931 |  |  |  |  |  |  | Adjudicated |  | PSS |  | 610494 | 9999 |  |  |  | N | N | Y | Y |  | 2 | 01/01/1900
UHC-RI-PSS | PSOUHCRI | UNITED HEALTHCARE RHODE ISLAND (PRESRIP SOLUTNS) | Lupron |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 610494 | 9999
PSV-COMCR | PSVCOMM | PSV COMMUNITY CARE |  |  |  | M/I PHARMACY NUMBER FOR ASSISTANCE TO RESOLVE THIS CLAIM REJECT GO TO WWW.EXPRESS-SCRIPTS.COM  ---Forward to Curascript | Non-matched pharmacy OR Pharmacy Not Contracted on DOS  VERIFY ESI ELIGIBILITY . If ESI does not recognize patient - FWD to [NAME] |  |  |  |  |  |  |  | 8772938628 |  |  |  |  |  |  | Adjudicated |  |  |  | 13550 |  |  |  |  | Y | N | Y | Y |  | 3 | 01/01/1900
REG | REGNCE | REGENCE RX |  |  |  |  |  |  |  |  |  |  |  |  | 8005720316 |  |  |  |  |  |  | Adjudicated |  |  |  | 610648 | 1890000 |  |  |  | N | N | Y | Y |  | 4 | 04/05/2010
REGENCERX | REGNCE2 | REGENCE RX |  |  |  |  |  |  |  |  |  |  |  |  | 8884371508 |  |  |  |  |  |  | Adjudicated |  |  |  | 610622 | 2070000 |  |  |  | N | N | Y | Y |  | 2 | 03/12/2010
RES | RESTAT | RESTAT |  |  |  |  |  | 11900 W LAKE PARK DRIVE |  |  | MILWAUKEE | WI | 53224 |  | 8002481062 |  | 4143385760 |  |  |  |  | Adjudicated |  |  |  | 600471 | 7777 |  |  |  | N | Y | N | N |  | 16 | 04/21/2010
EPN | RIVPN | RIVERSIDE PHYS [NAME] SOLUTION
RXA | RXA | RXAMERICA-CAREMARK |  |  |  |  |  | 369 BILLY MITCHELL ROAD |  |  | SALT LAKE CITY | UT | 84116 |  | (888) 321-2188 |  | 8667727737 | <<< PA |  |  |  | Adjudicated |  |  |  | 610473 | 787 |  |  |  | N | Y | Y | Y |  | 30 | 04/19/2010
RXA1 | RXA1 | RXAMERICA-CAREMARK |  |  |  |  |  | 369 BILLY MITCHELL ROAD |  |  | SALT LAKE CITY | UT | 84116 |  | 8666686681 |  | 8666686681 |  |  |  |  | Adjudicated |  |  |  | 610473 | 781 |  |  |  | N | Y | Y | Y |  | 3 | 03/12/2010
RXA-CARES1 | RXACARES | CARESOURCE-CAREMARK |  | 70 | PRODUCT SERVICE NOT COVERED | MD BUY AND BILL |  |  |  |  |  |  |  |  | 8666686681 |  |  |  | 8669300019 |  |  | Adjudicated |  |  |  | 610473 | 797 |  |  |  | N | N | Y | Y |  | 22 | [NAME]
RXA-CARESO | RXACARES | CARESOURCE-CAREMARK |  | 70 | PRODUCT SERVICE NOT COVERED | MD BUY AND BILL |  |  |  |  |  |  |  |  | 8666686681 |  |  |  |  |  |  | Adjudicated |  |  |  | 610473 | 797 |  |  |  | N | N | Y | Y |  | 1 | [NAME]
REDO | RXEDO | REDO |  |  |  |  |  | 1255 W 15TH ST. | SUITE 600 |  | PLANO | TX | 75075 |  | 8888797336 |  |  |  |  |  |  | Adjudicated |  |  |  | 610220 | 3980000 |  |  |  | N | N | Y | Y |  | 4 | 04/19/2010
RXNET | RXNET | [NAME] |  |  |  |  |  |  |  |  |  |  |  |  | 8002793022 |  |  |  |  |  |  | Adjudicated |  |  |  | 600471 | 296G |  |  |  | N | N | N | N |  | 1 | 01/01/1900
 | RXOPT | Advantage Health Options |  | 70 | PRODUCT SERVICE NOT COVERED | MD BUY AND BILL | PM excludes;DRUG COVERED UNDER MEDICAL
RX-OPTION | RXOPT | RX OPTION |  |  |  |  |  |  |  |  |  |  |  |  | 8003614542 |  |  |  |  |  |  | Adjudicated |  |  |  | 9893 | ROIRX |  |  |  | N | N | Y | Y |  | 28 | 04/27/2010
RX/PH/SOL | RXPS | RX PHARMACY SOLUTIONS |  |  |  |  |  | 33 NORTH ROAD |  |  | PEACE DALE | RI | 2883 |  | 8662513317 |  | 4809290799 |  |  |  |  | Adjudicated |  | MDI |  | 610140 |  |  |  |  | N | N | N | Y |  | 1 | 02/02/2005
RXWEST | RXWEST | RX WEST |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 8878
SAIS | SAIS | SUMMIT AMERICA INSURANCE SERV |  |  |  |  |  | 7400 COLLEGE BLVD. | SUITE 100 |  | OVERLAND PARK | KS | 66210 |  | 8772466997 | 3 |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
SAV | SAVRX | SAVE RX |  |  |  |  |  | 2355 WAUKEGAN RD. |  |  | DEERFIELD | IL |  |  | 8002283108 |  |  |  |  |  |  | Adjudicated |  |  |  | 6558 | HVI |  |  |  | N | N | N | Y |  | 24 | 04/26/2010
SCI | SCI | SCRIPT CARE |  |  |  |  |  | 2355 WAUKEGAN RD. |  |  | DEERFIELD | IL |  |  | 8008809988 |  |  |  |  |  |  | Adjudicated |  |  |  | 4410 | SCI |  |  |  | N | N | Y | Y |  | 12 | 04/09/2010
SCOT IND. | SCOTIND | SCOT INDUSTRIES INC |  |  |  |  |  | PO BOX 0146 |  |  | LONE STAR | TX | 75666 |  | 9036392551 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  | LISA |  | N | N | Y | Y |  | 1 | 01/01/1900
SCRIPTSAVE | SCRPTSV | SCRIPTSAVE |  |  |  |  |  | 2355 WAUKEGAN RD |  |  | DEERFIELD | IL | 60015 |  | 8004041031 |  |  |  |  |  |  | Adjudicated |  |  |  | 6053 | MSC |  |  |  | N | N | N | N |  | 32 | 01/01/1900
ARG-SCT&WH | SCTWHT | SCOTT & WHITE |  |  |  |  |  |  |  |  |  |  |  |  | 8005227487 |  | 8007287947 |  |  |  |  | Adjudicated |  | ARG |  | 610141 | 2500000 |  |  |  | N | N | Y | Y |  | 3 | 03/03/2004
SELECT1 | SELECT1 | SELECT CARE |  |  |  |  |  | P.O. BOX 830489 |  |  | BIRMINGHAM | AL | 35283 | 489 | 8772331800 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 04/14/2010
S/P | SELFPAY | SELF PAY |  |  |  | Add to patient profile when paying cash for their shipment |  |  |  |  |  | P
S/P | SELFPAY | SELF PAY |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | P |  |  |  |  |  |  |  |  | N | N | N | N |  | 20 | 03/02/1999
SLTHEALTH | SELHLTH | SELECT HEALTH |  |  |  | CHECK CONTRACT JOB AID | CONTRACT - NO PA REQ'D | PO BOX 30192 |  |  | SALT LAKE CITY | UT | 84130 |  | 8005385038 |  | 8014425038 |  |  |  |  | HCFA | [PHONE] |  |  |  |  | 870409820 | LACY |  | N | N | N | N |  | 42 | 04/27/2010
SPS | SERVU | SERV-U PRESCRIPTION |  |  |  |  |  | PO BOX 23237 |  |  | MILWAUKEE | WI | 53223 | 237 | 8007593203 |  |  |  |  |  |  | Adjudicated |  |  |  | 1553 | SERVU |  |  |  | N | N | N | N |  | 5 | 04/22/2010
SECHLTH | SHPGA | SECURE HEALTH PLANS OF GEORGIA |  |  |  |  |  | P.O. BOX 13447 |  |  | MACON | GA | 31208 | 3447 | 8006487563 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 03/26/2010
SOUND | SHW | SOUND HEALTH & WELLNESS |  |  |  |  |  | P.O. BOX 2265 |  |  | SEATTLE | WA | 98111 | 2265 | 8002257620 |  | 2062824500 |  | 2062854437 |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
STUDASSUR | STUDENT | STUDENT ASSURANCE SERVICES
ST VINCENT | STVINCE | ST [NAME] |  |  |  |  | CONTRACT - PA REQ'D | 17215 STUDEBAKER ROAD | SUITE 220 |  | CERRITOS | CA | 90703 |  | 5628608771 | 101 |  |  | 5629241603 |  |  | HCFA |  |  |  |  |  |  | MARIAGONZALES |  | N | N | N | N |  | 11 | 04/22/2010
SXC/H1ST | SXCH1ST | HEALTH FIRST |  |  |  |  |  |  |  |  |  |  |  |  | 8777748729 |  | 8667150876 |  |  |  |  | Adjudicated |  | SXC |  | 610593 | SXC |  |  |  | N | N | Y | Y |  | 6 | 01/01/1900
SXC | SXCI | SXC HEALTH SOLUTIONS INC |  |  |  |  |  | 7047 E GREENWAY PKWY | SUITE 370 |  | SCOTTSDALE | AZ | 85254 |  | 8667150876 |  |  |  |  |  |  | Adjudicated |  |  |  | 610593 | 3SHP |  |  |  | N | N | N | Y |  | 1 | 04/15/2010
SXC-MHP | SXCMHP | HEALTH NEW ENGLAND |  |  |  |  |  |  |  |  |  |  |  |  | 8009187545 |  |  |  |  |  |  | Adjudicated |  |  |  | 610593 | MHP |  |  |  | N | N | Y | Y |  | 2 | 04/12/2010
SXC/NHP | SXCNHP | NEIGHBORHOOD HEALTH PLAN RX |  |  |  |  |  |  |  |  |  |  |  |  | 8009187545 |  | 8009631001 |  |  |  |  | Adjudicated |  | SXC |  | 610593 | SXC |  |  |  | N | N | Y | Y |  | 5 | 04/01/2005
SXC/PRESBY | SXCPRESB | PRESBYTERIAN HEALTH PLAN |  |  |  |  |  |  |  |  |  |  |  |  | 8665285829 |  | 8889235757 |  |  |  |  | Adjudicated |  |  |  | 610593 | SXC |  |  |  | N | N | Y | Y |  | 7 | 04/14/2010
SXC-VA | SXCVA | VA-CAP |  |  |  |  |  | 7047 E GREENWAY PKWY |  |  | SCOTTSDALE | AZ | 85254 |  | 8007338387 |  |  |  |  |  |  | Adjudicated |  |  |  | 610593 | VA |  |  |  | N | N | Y | Y |  | 4 | 03/30/2010
TDI | TDI | TDI MANAGED CARE |  |  |  |  |  | 620 EPSILON DRIVE |  |  | PITTSBURGH | PA | 1 | 5238 | 8007855301 |  | 8005815300 |  |  |  |  | Adjudicated |  | PHA |  | 610474 | TDI |  |  |  | N | N | Y | Y |  | 8 | 01/19/2009
TEAMSTRX | TEAMSTRX | TEAMSTERS |  |  |  |  |  |  |  |  |  |  |  |  | 8668880103 |  | 6034322505 |  |  |  |  | Adjudicated |  |  |  | 11883 |  |  |  |  | N | N | N | Y |  | 5 | [NAME]
PMK-IN | TNCARE | PRO-MARK (TENN CARE) |  |  |  |  |  |  |  |  |  |  |  |  | 8002135640 |  |  |  |  |  |  | Adjudicated |  | MIM |  | 900020 | CLAIMNE |  |  |  | N | Y | N | Y |  | 2 | 03/31/2004
TOTRX | TOTRX | TOTAL RX |  |  |  |  |  |  |  |  |  |  |  |  | 8007522211 |  |  |  |  |  |  | Adjudicated |  | MIM |  | 6524 | TSCRIPT |  |  |  | N | N | N | Y |  | 2 | 11/03/2004
TRI-EXP | TRICARE | EXPRESS SCRIPTS-TRICARE | Lupron | 5 | M/I SERVICE PROVIDER NUMBER | FORWARD TO CURASCRIPT |  |  |  |  |  |  |  |  | (877)363-1304 |  |  |  |  |  | TRICARE | Adjudicated |  | EXP |  | 3858 | A4 |  |  |  | N | N | Y | Y |  | 158 | 07/07/2004
TXM | TXMLG | TEXAS MUNICIPAL LEAGUE GROUP |  |  |  |  |  | P.O. BOX 149191 |  |  | AUSTIN | TX | 78714 | 9191 | 8888182822 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | [NAME]
TRUECHO | TXTRUCHO | TEXAS TRUE CHOICE |  |  |  |  |  | PO BOX 251369 |  |  | PLANO | TX | 75025 |  | 8008253540 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 05/25/2007
UHC-MD | UHC | UNITED HEALTHCARE-MARYLAND | Lupron |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  |  |  |  |  |  |  |  | 8003106826 |  | 8009221557 |  |  |  |  | Adjudicated |  | PD | KMH | 610084 | PRODUR1 |  |  |  | N | N | Y | Y |  | 1 | 01/02/2008
UMR-30541 | UMR1 | UMR |  |  |  |  |  | P.O. BOX 30541 |  |  | SALT LAKE CITY | UT | 84130 | 541 | 8668683645 |  | 8005575087 |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 2 | 01/01/1900
UMR | UMR2 | UNITED MEDICAL RESOURCES | Lupron |  |  | FORWARD TO PRESCRIPTION SOLUTIONS |  | P.O. BOX 141337 |  |  | CINCINNATI | OH | 45250 | 1337 | 8008605251 |  |  |  |  |  |  | HCFA |  |  |  |  |  | 31-107858 |  |  | N | N | N | N |  | 1 | 05/06/1999
UMR-0783 | [NAME] | UMR |  |  |  |  |  | P.O. BOX 30783 |  |  | SALT LAKE CITY | UT | 84130 | 783 | 8003677125 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
UMR-MIDWES | UMRMSA | MIDWEST SECURITY ADMINISTRATION
UNTDRG | UNITED | UNITED DRUG |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 4428 | UDI
UPS | UPSVC | UNITED PROVIDER SERVICES |  |  |  |  |  | BOX 820277 |  |  | FORT WORTH | TX | 76182 | 277 | 8005198374 |  |  |  |  |  |  | Adjudicated |  | PHA |  | 610449 | 4116PQC |  |  |  | N | Y | Y | Y |  | 4 | 10/06/2009
US/SCRP | USSCRPT | US SCRIPTS |  |  |  |  |  | 1300 EAST SHAW | STE 173 |  | FRESNO | CA | 93710 |  | 8004608988 |  |  |  |  |  |  | Adjudicated |  |  |  | 8019 | USS |  |  |  | N | N | Y | Y |  | 11 | 12/10/2008
AMVERMED | VETMED | AMERICA VETERINARIAN MED ASSOC |  |  |  |  |  | P.O. BOX 909720 |  |  | CHICAGO | IL | 60690 | 9720 | 8006216360 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | N | N |  | 1 | 04/06/2010
WELL [NAME] | WDYNE | WELL DYNE RX |  |  |  |  |  |  |  |  |  |  |  |  | 8888865822 |  |  |  |  |  |  | Adjudicated |  |  |  | 8878 |  |  |  |  | N | N | N | Y |  | 7 | 04/15/2010
WELL/PW | WELPWR | WELL POWER |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 3585 | 34625
WHP | WHI | WALGREENS HEALTH INITIATIVES |  |  |  |  |  | P.O. BOX 545 |  |  | DEERFIELD | IL | 60015 |  | 8002072568 |  | 8776656609 |  |  |  |  | Adjudicated |  | WHP |  | 603286 | 1410000 |  |  |  | N | N | Y | Y |  | 85 | 04/27/2010
WPPA | WPPA | WPPA |  |  |  |  |  | 1020 SOUTH HILL SIDE |  |  | WITCHITA | KS | 66604 |  | 8004754445 |  |  |  |  |  |  | HCFA |  |  |  |  |  |  |  |  | N | N | Y | Y |  | 1 | 01/01/1900
LOCAL1199 |  | 1199 NATIONAL BENEFIT FUND |  |  |  | CHECK HIP ELIGIBILITY CHECK MEDCO ELIGIBILITY |  |  |  |  |  |  |  |  | (646) 473-7160 |  |  |  |  |  | 1199
 |  | ARIZONA HEALTH CARE COST CONTAINMENT  SYSTEM (AHCCCS) | Lupron
 |  | BCBS OF WESTERN NY |  |  |  | PBM SHOULD BE MEDCO
 |  | [NAME] HEALTH PLAN EAST |  |  |  | IF FUTURE SCRIPTS IS PBM, OBTAIN VALID REJECTION AND FORWARD TO CAREMARK
VARIABLE14 | VARPRO | VARIABLE PROTECTION