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Montana
Montana Department of Public Health and Human Services
Pharmacy Online Rate Review Request
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Montana: Average Acquisition Cost Program (AAC) Request for Medicaid Reimbursement Review
Pharmacy Provider Information:
Pharmacy providers should use this form to submit AAC pricing inquiries. All fields must be complete 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)
Contact Information
Submitter's Name
(Required)
First
Last
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:
PBM / Payer Name:
(Required)
Dispense Date:
(Required)
Quantity Dispensed:
(Required)
Dispensing Fee:
(Required)
Total Reimbursement for Claim:
(Required)
(Including dispensing fee)
Additional Drug Information:
Is this a recent change in reimbursement?
(Required)
Yes
No
Is this a recent increase in acquisition cost?
(Required)
Yes
No
If yes, what was your aquisition cost prior to cost increase?
(Required)
Is there an availability issue?
(Required)
Yes
No
If yes, reason for the issue?
(Required)
Are you able to purchase alternate NDCs?
(Required)
Yes
No
If yes, please send a copy or screen shot of your alternate NDC information including acquisition cost.
(Required)
Max. file size: 100 MB.
Attach your purchase record or invoice here:
Max. file size: 100 MB.
Comments:
Myers and Stauffer Montana Help Desk: Fax: 317-571-8481, Email: MTPharmacy@mslc.com. Forms submitted without purchase record or invoice supporting your acquisition cost will not be considered for review. Once complete information is received, we will evaluate your inquiry and respond within 48 business hours. For questions or to check the status of an inquiry please contact us by email at copharmacy@mslc.com or by phone at 800-591-1183.
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