Pharmacy providers should use this form to report problems purchasing drugs at prices equivalent to or less than established State Average Acquisition Cost (SAAC) reimbursement rates.

For a downloadable Acrobat PDF version of this document click here.


Pharmacy Provider Information   
Pharmacy Name  
City   State
Phone   E-Mail
Drug Information   
Drug Name 
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?
Package Size
Are there availability issues?
Date of Purchase
Are you able to purchase alternate NDCs?
Claim Information  
Dispense Date
Quantity Dispensed  
Dispensing Fee $  
Total Reimbursement for Claim $ 
Medicaid co-pay due from recipient $ 
NOTE:   You must fax to (317) 571-8481 (Attention: Pharmacy Unit) or e-mail to 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