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(Monday-Friday, 7:30 a.m. to 6:30 p.m. Central time)

Fax Verification Form

Pharmacy providers should attempt to bill the third-party payer in question before submitting the Third-Party Payer Verification Form (PDF) to confirm whether any information has changed or the policy has terminated.  The Third-Party Call Center cannot process the request until the pharmacy has received a denial from the third-party payer.

Fax the completed form and any third-party denial responses received to 1-866-389-6342.  The form will be processed within three business days.