Pharmacy providers should use this form to report problems purchasing drugs at prices equivalent to or less than established Average Acquisition Cost (AAC) reimbursement rates. PLEASE DO NOT INCLUDE ANY PERSONAL HEALTH INFORMATION (PHI) WITH SUBMITTED FORM OR INVOICE.

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Pharmacy Provider Information   
Pharmacy Name  
NPI  
City   State
Phone  
[##########]
E-Mail
 
Drug Information   
Drug Name 
National Drug Code (NDC)  
[###########]

Provider Cost Information
Cost Per Package $ 
Package Size
Date of Purchase
[MM/DD/YYYY]
Claim Information  
Dispense Date
[MM/DD/YYYY]
 
Quantity Dispensed  
Dispensing Fee $  
Total Reimbursement for Claim $ 
Medicaid co-pay due from recipient $ 
 
Is this a recent change in reimbursement?
Has there been a recent increase in acquisition cost?
If yes, what was your old acquisition cost prior to rate increase? $
Are there availability issues?
If yes, reason for the issue?
Are you able to purchase alternate NDCs?
If yes, what alternate NDCs are available?
[###########]
If no, do you have a secondary wholesaler?
If no, can you get a secondary wholesaler?
 
Comments:
 
NOTE:   You must fax to (317) 571-8481 (Attention: Pharmacy Unit) or e-mail to idpharmacy@mslc.com copies of your purchase records that confirms your acquisition costs in addition to alternate NDC information.
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 idpharmacy@mslc.com or by phone at 800-591-1183.
 
Person Submitting This Request