Louisiana Rate Review Request

Louisiana Clotting Factor Average Acquisition Cost Program (AAC) – Request for Medicaid Reimbursement Review

Pharmacy providers should use this form to submit Clotting Factor AAC pricing inquiries.

Pharmacy Provider Information:

ALL FIELDS MUST BE COMPLETED FOR PROPER SUBMISSION OF THIS FORM. PLEASE DO NOT INCLUDE ANY PERSONAL HEALTH INFORMATION (PHI) WITH SUBMITTED FORM OR INVOICE.

Pharmacy Name:(Required)

NPI:(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone:(Required)

Email:(Required)

Drug Information:

Please enter information for one (1) drug per submission form

Drug Name and Strength:(Required)

National Drug Code (NDC):(Required)

Provider Cost Information:

Cost Per Package:(Required)

Package Size:(Required)

Date of Purchase:(Required)

Claim Information:

Dispense Date:(Required)

Quantity Dispensed:(Required)

Dispensing Fee:(Required)

Total Reimbursement for Claim:(Required)

(Including dispensing fee)

Medicaid Co-Pay Due From Recipient:(Required)

Additional Drug Information:

Is this a recent change in reimbursement?(Required)

Yes

Is this a recent increase in acquisition cost?(Required)

Yes

If yes, what was your aquisition cost prior to cost increase?(Required)

Is there an availability issue?(Required)

Yes

If yes, reason for the issue?(Required)

Are you able to purchase alternate NDCs?(Required)

Yes

If yes, what alternate NDCs are avaliable?(Required)

If no, do you have a secondary wholesaler?(Required)

If no, can you get a secondary wholesaler?(Required)

Attach your purchase record or invoice here:

Max. file size: 1 MB.

Comments:

Please print and fax this form to 317-571-8481 (attention: Pharmacy Unit) or e-mail this form to lapharmacy@mslc.com. Be sure to include 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 e-mail at lapharmacy@mslc.com or by phone at 800-591-1183.

Submitter's Name:(Required)

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