Free 1-Price Pharmacy Provider Enrollment

INDEPENDENT PHARMACY NETWORK ENROLLMENT FORM FOR THE 1-PRICE PRESCRIPTION PLAN

Patient Pricing Schedule
Brand
AWP – 8% + $2.50
Generic Formulary Drugs

$18.00 per 100 Units
$48.00 per 300 Units
$34.00 per 200 Units
$60.00 per 400 Units

Or As Listed on Formulary (Lower Tier Drugs $12.00)
Generic Non-Formulary Drugs
AWP – 30% + $3.50

Note: The Pharmacy Benefit Administrator charges a $2.00 Transaction Fee only for adjudicated claims. This fee will be billed to you on a bi-monthly basis by Pharmacy Development Services. Eligible members will receive a 25% rebate of this Transaction Fee.

By joining the independent pharmacy network, you are simply provided the material to review and the opportunity to offer the 1-Price Prescription Plan if you wish. You are under no obligation to accept this plan if you choose not to.

Yes, I will be a Provider for the PharmAvail Benefit Management Network for the 1-Price Prescription Plan. I understand that by signing and returning this form to PharmAvail Benefit Management, the pharmacy listed below will be added to the PharmAvail Benefit Management Network at the parameters PharmAvail Benefit Management has stated above.

Please complete the information below. If a pharmacy chain, please complete the information for the specific store location.

Pharmacy Name:

NABP Number or NCPDP Chain Code:

NPI Number:

Location or Corporate Address:

Address line 2 (Suite, Bldg, etc.):

City:

State:

Zip Code:

Phone Number:

Authorizing Person:

Email:

If you have questions, or need further explanation, please call
Pharmacy Development Services at (800)987-7386 9am-5pm Eastern Time Weekdays
Note: Pharmacy Billing Information

Transmit Claims to US Script/PharmAvail Bin # 008019 Group # 7606

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