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Welcome Providers

Resources & Information

We're dedicated to bringing you the information you need to best care for your patients. Here you can quickly access processing information, pharmacy enrollment requests, electronic pay information, MAC disputes and more.

Independent pharmacies must fill out the FWA Attestation located in Part 1 of pharmacy's NCPDP Profile.

Questions? Please call our Pharmacy Help Desk at 1-800-361-4542 or visit the contact us page.

Pharmacies located in Puerto Rico, calling on behalf of MCS claims may call 1-844-633-1064.

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Pharmacy Resources

Enroll - Joining Our Network

To join the MedImpact Network, please visit the Pharmacy Portal

The instructions to complete the enrollment process are included in the User Guide

Processing Information

Please use the following links to ensure correct processing:

Electronic Payment and Remittance

We are happy to provide our participating pharmacies with the opportunity to receive payment electronically via ACH and remittance details electronically in HIPAA 835 format. You must submit all forms to PharmacyPayables@elixirsolutions.com in order for your request to be processed.

Download the Payment and Remittance forms.

Download the instructions.

Please contact us at PharmacyPayables@elixirsolutions.com with any questions.

MAC Pricing

In order to submit an appeal please use this Excel form and send to mac-elixir@medimpact.com. Email Subject should include the name of the Pharmacy appealing as well as the date the appeal is being submitted, if only for one drug include the RX Number as well. All appeals must be filed within 90 Days of the Fill Date and contain all the information below, with cell type in parentheses, to be processed:

RX Number (Text)
Fill Date (MM/DD/YYYY)
NDC (Text)
NCPDP (Text)
GroupID (Text)
RXBin (Text)
Quantity Dispensed (Number)
Acquisition Price (Currency $XX.XXXXX)
Drug and Strength (Text)

Appeals will be processed in the order they are received and responded to within seven business days from mac-elixir@medimpact.com with the result including a reason for approval/denial. If you disagree with an appeals decision, you can file a second appeal by including the invoice and it will be handled on the same cadence as the original appeal.

An initial appeal process is available for all prescription drugs in applicable states such as Tennessee for which a pharmacy alleges that it did not receive its actual cost. You can initiate an initial appeal by using the appeals method described above.

MAC pricing is also available to pharmacies upon request by calling the Help Desk at 1-800-361-4542 or emailing mac-elixir@medimpact.com

Pharmacies may contact us with MAC concerns at mac-elixir@medimpact.com or through the Help Desk at 1-800-361-4542.

Pharmacies located in Puerto Rico, calling on behalf of MCS claims may contact us with MAC concerns at mac-elixir@medimpact.com or call 1-844-633-1064.

Indiana licensed pharmacies may click here to see the current MAC pricing. MAC prices reflect the lowest price payable to Indiana pharmacies; actual amounts paid to Indiana pharmacies may be higher than the amounts listed (e.g., MAC price may be higher based on particular plans and/or regions).

This MAC list is CONFIDENTIAL AND PROPRIETARY to MedImpact and contains material MedImpact may consider Trade Secrets. This MAC list is being provided for specified use as required by law and may not otherwise be used, reproduced, transmitted, published, or disclosed to others without prior written authorization from MedImpact. MedImpact maintains the sole and exclusive ownership, right, title, and interest in and to this MAC list. Without limiting the generality of the foregoing, pharmacy providers shall not attempt to replicate the information contained in this MAC lists and shall not use the information contained herein in a manner that places MedImpact at a commercial disadvantage. Pharmacy providers shall allow only designated individuals who agree to the confidentiality protections herein to have access to this MAC list and the information contained herein.

To the extent that state or federal law is more restrictive than the policy outlined above, MedImpact will adhere to the more restrictive requirement.

Pharmacy Audits

Health Information & Resources

Please note that by clicking these links, you may be leaving this website.

Professional comment form
Adverse drug reporting
Learn more about specific medications
Learn more about specific conditions:
Pharmaceutical Management Procedures
- Utilization Management: If you would like to obtain a copy of the UM criteria or additional information on how coverage determinations are made, please call 800-361-4542 and our customer care team will be happy to assist you.
- Copays: For more information about medication copays and formulary tiers, please call 800-361-4542 and our customer care team will be happy to assist you.
- Prior authorization:
  - If the prescribed medication requires a Prior Authorization, you can request a "Coverage Determination Request" asking the plan to review the request to approve coverage of the medication.
    - To Submit a Prior Authorization Request:
    - Click here: Online Coverage Determination for the PromptPA Web Portal
    - Select the "Prescriber" link
    - Complete each screen as prompted and click "Next" and then "Finalize"
    - Your request will be sent to us for review
- Exceptions: If the member's medication is not covered or they require an exception to the formulary medication, an "Exception Request" (request to cover the medication) can be made to ask the plan for a review to cover the medication.
  - To Submit an Exception Request:
    - Click here: Online Coverage Determination for the PromptPA Web Portal
    - Select the "Prescriber" link
    - Complete each screen as prompted and click "Next" and then "Finalize"
    - Your request will be sent to us for review
- Quantity Limit restrictions: We may only cover a drug up to a determined quantity or amount. You can request a quantity limit exception for the member if you feel it is medically necessary to exceed these limits. The quantity limit exception requires approval before the higher quantity will be covered. Quantity Limits are generally used as a safety precaution to prevent certain prescription drugs from being over-utilized.
  - Limited Access refers to prescriptions that may only be available at certain pharmacies. For more information call Customer Care at 800-361-4542.
  - Certain covered drugs require step-therapy. Step therapy is a requirement that encourages the member to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition the plan may require you to try Drug A first. If Drug A does not work for the member, the plan will then cover Drug B.
- Generic substitution: We do not automatically issue generic substitutions or therapeutic interchange, although brand name drugs may not be on the formulary and may require an exception.

For any other questions regarding how to use our pharmaceutical management procedures or the content within, please call 800-361-4542 and our customer care team will be happy to assist you.

Utilization Management Statement

Utilization Management decision making is based only on appropriateness of care and service and existence of coverage.
The organization does not specifically reward practitioners or other individuals for issuing denials of coverage.
Financial incentives for Utilization Management decision makers do not encourage decisions that result in underutilization.

Prescriber Resources

We're dedicated to bringing you the information you need to best care for your patients. Here you can quickly access coverage determination links, forms, and other helpful information.

The Pharmacy and Therapeutics (P & T) Committee is a multidisciplinary team of physicians, pharmacists, and other health care professionals that provides clinical oversight of the drug utilization management process. This information is available to prescribers upon request. For any questions, please contact us.

Coverage Determination Links

Coverage Determination Forms

General Forms:

State of Colorado Form

Colorado Prior Authorization Form

State of Illinois Form

Illinois Prior Authorization Form

State of Maryland Forms

State of Oklahoma Form

Oklahoma Prior Authorization Form

Covered Drug Lists

The following are lists of the most commonly prescribed brand medications. They represent an abbreviated version of the drug list (formulary) that is at the core of each prescription-drug benefit plan. These lists are not all-inclusive and do not guarantee coverage. In addition to drugs on these lists, the majority of generic medications are covered and members are encouraged to ask their doctor to prescribe generic drugs whenever appropriate.

The Pharmacy and Therapeutics Committee is responsible for the development and maintenance of the Formularies. The Committee is comprised of independent practicing physicians and pharmacists from a wide variety of medical specialties. The formularies are reviewed and updated as new drugs or new prescribing information becomes available.

Factors which affect decisions regarding the formulary include safe use, clinical efficacy, and therapeutic need. Cost is considered only after all other factors are assessed. Compliance with the formulary is important for improving quality of care and restraining health care costs. As a component of formulary compliance, preferred brand drugs may be moved to non-preferred status if a generic version becomes available during the year. Any medication approved to enter the market will not be covered until reviewed by the Pharmacy and Therapeutics Committee. These lists may be subject to change and not all drugs listed are covered by all prescription-drug benefit programs.

2024:

2023:

Health Information and Resources

Please note that by clicking these links, you may be leaving this website.

Professional comment form
Adverse drug reporting
Learn more about specific medications
Pharmaceutical Management Procedures
- Utilization Management: If you would like to obtain a copy of the UM criteria or additional information on how coverage determinations are made, please call 800-361-4542 and our customer care team will be happy to assist you.
- Criteria forms are also available for download on this page
- Covered Drug Lists: For more information on covered medications or formulary updates please see the current year "Covered Drug Lists" Covered Drug Lists
- Copays: For more information about medication copays and formulary tiers, please call 800-361-4542 and our customer care team will be happy to assist you.
- Prior authorization:
  - If the prescribed medication requires a Prior Authorization, you can request a "Coverage Determination Request" asking the plan to review the request to approve coverage of the medication.
    - To Submit a Prior Authorization Request:
      - Click here for the PromptPA Web Portal
      - Within the Portal, select the "Prescriber" link to begin
      - Fill out each screen within the portal as prompted and click "Next"
      - When you get to the last screen, click "Finalize"
      - Your request will be sent to us for review
- Exceptions: If the member's medication is not covered or they require an exception to the formulary medication, an "Exception Request" (request to cover the medication) can be made to ask the plan for a review to cover the medication.
  - To Submit an Exception Request:
    - Click here for the PromptPA Web Portal
    - Within the Portal, select the "Prescriber" link to begin
    - Fill out each screen within the portal as prompted and click "Next"
    - When you get to the last screen, click "Finalize"
    - Your request will be sent to us for review
- Quantity Limit restrictions: We may only cover a drug up to a determined quantity or amount. You can request a quantity limit exception for the member if you feel it is medically necessary to exceed these limits. The quantity limit exception requires approval before the higher quantity will be covered. Quantity Limits are generally used as a safety precaution to prevent certain prescription drugs from being over-utilized.
  - Limited Access refers to prescriptions that may only be available at certain pharmacies. For more information call Customer Care at 800-361-4542.
  - Certain covered drugs require step-therapy. Step therapy is a requirement that encourages the member to try less costly but just as effective drugs before the plan covers another drug. For example, if Drug A and Drug B treat the same medical condition the plan may require you to try Drug A first. If Drug A does not work for the member, the plan will then cover Drug B.
- Generic substitution: We do not automatically issue generic substitutions or therapeutic interchange, although brand name drugs may not be on the formulary and may require an exception.

For any other questions regarding how to use our pharmaceutical management procedures or the content within, please call 800-361-4542 and our customer care team will be happy to assist you.

Additional Provider Support

Please note that by clicking these links, you may be leaving this website.

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