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.
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: firstname.lastname@example.org. 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 email@example.com or by phone at 800-591-1183.