Pharmacy Online Rate Review Request

Utah: 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. For a downloadable Acrobat PDF version of this document, see the AAC Rate Review section on the main Utah pharmacy page.

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:

PBM / Payer Name:(Required)

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, please send a copy or screen shot of your alternate NDC information including acquisition cost.(Required)

Max. file size: 10 MB.

Comments:

Please fax or email the completed form along with your purchase record or invoice supporting acquisition cost and alternate NDC information to: Myers and Stauffer Utah Help Desk: Fax: 317-571-8481, Email: utpharmacy@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 utpharmacy@mslc.com or by phone at 800-591-1183.

Submitter's Name:(Required)

First Last