Pharmacy providers should use this form to report problems purchasing drugs at prices equivalent to or less than established Average Actual Acquisition Cost (AAC) reimbursement rates.
For a downloadable Acrobat PDF version of this document
Pharmacy Provider Information
National Drug Code (NDC)
Provider Cost Information
Is this a recent change in reimbursement?
Cost Per Package
Has there been a recent increase in acquisition cost?
Are there availability issues?
Date of Purchase
Are you able to purchase alternate NDCs?
Total Reimbursement for Claim
Medicaid co-pay due from recipient
You must fax to (317) 571-8481 (Attention: Pharmacy Unit) or e-mail to firstname.lastname@example.org copies of your purchase records that illustrate your costs.
Once complete information is received, we will evaluate your inquiry and respond within 24 hours. For questions or to check the status of an inquiry, please contact us by email at
or by phone at 800-591-1183.
Person Submitting This Request