Forms and Manuals

• Pharmacy Providers
  • Pharmacy Application Process
  • Handbooks/Payer Sheets
  • Continuing Education
• Preferred Drug List
  • P&T Recommendations
  • P&T Decisions
• Drug Utilization
  • Drug Criteria
  • Clinical Edits
  • Prior Approval request forms
• Delimited Text File download
• Claims Forms

All forms are in PDF format unless otherwise indicated.

Handbooks/Payer Sheets

Pharmacy Provider Handbook

Pharmacy Provider Procedure Manual (eff. Dec. 2011)

• Claims Adjudication (Transaction Code B1) Payer Sheets
  • B1 Billing Request (version D.Ø)
  • B1 Paid Response (version D.Ø)
  • B1 Rejected Response (version D.Ø)
• Claims Reversal (Transaction Code B2) Payer Sheets
  • B2 Reversal Request (version D.Ø)
  • B2 Reversal Accepted Response (version D.Ø)
  • B2 Reversal Rejected Response (version D.Ø)
• Eligibility Verification (Transaction Code E1) payer sheets
  • E1 Eligibility Verification Request (version D.Ø)
  • E1 Eligibility Accepted Response (version D.Ø)
  • E1 Eligibility Rejected Response (version D.Ø)

Claim forms

• Form 3700: Pharmacy Claims Billing Request
• Retroactive Claim Instructions
• Retroactive Claim Fax Form
• Third Party Payer Verification Request form

Continuing Education

• 72-hour Emergency Override of a PA-Required Drug (PDF)
• STAR Health Foster Care claim submittal (PDF)
• About Vendor Drug brochure
• Continuing Education flyer

Delimited Text Files

• Texas Drug Code Formulary (updated 02/21/12)
• Texas Drug Code MAC (Maximum Allowable Cost) Formulary (updated 02/21/12)
• Prescriber Index (updated 02/06/12)